Presented  by 
Edward  S.  Merrill,  D.o, 


COLLEGE    OF    OSTEOPATHIC    PHYSICIANS 
AND  SURGEONS  •    LOS  ANGELES,  CALIFORNIA 


' 


<\    I    b 


THE  NARCOTIC  DRUG  DISEASES 

AND 

ALLIED  AILMENTS  ^ 

PATHOLOGY,  PATHOGENESIS,  and  TREATMENT 


, 
GEO'.'E.  PETTEY,  M.D., 

MEMPHIS,  TENNESSEE 

MEMBER,  MEMPHIS  AND  SHELBY   COUNTY   MEDICAL   SOCIETY,  TENNESSEE   STATE 
MEDICAL  ASSOCIATION,  AMERICAN  MEDICAL  ASSOCIATION,  TRI-STATE  MEDICAL 
ASSOCIATION  OF  MISSISSIPPI,  ARKANSAS,  AND  TENNESSEE;  ALSO  MISSIS- 
SIPPI VALLEY  MEDICAL  ASSOCIATION,    SOUTHERN  MEDICAL 
ASSOCIATION,  AND  OF  THE  AMERICAN  SOCIETY 
FOR  THE  STUDY  OF  ALCOHOL  AND 
NARCOTIC  DISEASES. 


ILLUSTRATED 


PHILADELPHIA 

F.  A.  DAVIS  COMPANY,  PUBLISHERS 
1913 


VU/W91  TO 

P  Mf<]  \\ 

v'Xis 


COPYRIGHT,  1913 

BY 

GEO.  E.  PETTEY,  M.D. 
All  Rights  Reserved 


Philadelphia,  Pa.,  U.  S.  A. 

Press  of  F.  A.  Davis  Company 

1914-1916  Cherry  Street 


TO    the    Man    who    is    Helpless    and   yet    Hopes, 
who  Longs  for  Freedom,  who  Strives  against 
Odds  Unequal  while  No  One  Seems  to  See,  or  Care 
to    Help,    This    Book    is    Offered    as    a    Ground    for 
Hope,   a   Rift   in   the   Clouds,   a   Helping   Hand. 


INTRODUCTORY. 


THE  conviction,  reinforced  by  long  experience,  that 
drug  habitues  are,  in  most  cases,  the  blameless  victims  of 
disease,  and  that  they  not  only  merit  sympathy  and  con- 
sideration, but  are  entitled  to  rational  and  skillful  medi- 
cal aid,  such  as  is  accorded  the  sufferers  from  other 
physical  ailments,  has  impelled  the  author  to  write  and 
publish  this  work. 

This  volume  treats  narcotic  addiction  as  a  disease, 
a  toxemia,  of  drug,  auto-  and  intestinal  origin,  the 
management  and  treatment  of  which  belong  to  the  field 
of  internal  medicine  and  not  to  neurology. 

The  vital  and  essential  principle  of  the  treatment  ad- 
vocated is  elimination.  This  method,  with  all  its  auxil- 
iaries, is  presented  herein  in  detail,  and  furnishes  a 
rational  basis  for  the  scientific  medication  and  humane 
management  of  these  cases. 

In  order  to  make  this  monograph  of  greater  direct 
value  to  the  general  practitioner,  who  may  be  more 
concerned  with  collateral  subjects  than  with  the  treat- 
ment of  narcotic  addiction,  much  space  is  devoted  to  the 
treatment  of  acute  ailments  occurring  in  narcotic  and 
alcoholic  habitues,  to  the  withdrawal  of  narcotics  after 
prolonged  use  during  acute  ailments,  the  management  of 
infants  born  of  drug-using  mothers,  the  treatment  of 

(v) 


C\  f\-  i~\  /-k  n 


vi  Introductory. 

delirium  tremens,  and  "sobering-up"  the  victims  of  acute 
alcoholism. 

Certain  propositions  are  so  essential  to  a  clear  under- 
standing of  the  subjects  considered  in  this  work  that  the 
author  has  thought  best  to  repeat  some  of  these  funda- 
mental propositions  in  the  various  connections  in  which 
they  should  be  considered,  rather  than  to  depend  upon 
cross-references.  These  repetitions  will  doubtless  mar 
the  work  in  the  eyes  of  a  reviewer,  but  it  is  confidently 
believed  that  this  arrangement  of  the  matter  more  effect- 
ively teaches  the  subject,  and  makes  the  volume  of  more 
practical  value  as  a  reference  work  than  could  have  been 
done  had  cross-references  alone  been  depended  upon. 

MEMPHIS,  fftntf  GE°'  E'  PETTEY- 


CONTENTS. 


CHAPTER  PAGE 

INTRODUCTORY  v 

I.     History,  Definitions,  Pathology,  Etiology 1-27 

II.  Symptomatology.  Symptoms  indicating  the  use  of  opiates. 
Symptoms  indicating  the  use  of  other  drugs  with  other 
opiates.  Symptoms  which  indicate  the  deprivation  of  the 
accustomed  drug,  and  others  which  may  be  expected  to 
develop  under  gradual  withdrawal.  Symptoms  which 
arise  under  the  suppression  of  opiates  28-50 

III.  Treatment   51-79 

IV.  Treatment  continued.     Case  reports,  etc 80-96 

V.     Treatment  continued.     Clinical  reports,  etc 97-127 

VI.  Treatment  continued.  Treatment  of  drug  disease  in  preg- 
nant women,  etc.  Treatment  during  convalescence  of 
addiction  acquired  in  acute  ailment.  Structural  heart 
lesions  complicating  morphinism.  Age  not  a  bar  to 
treatment 128-141 

VII.     Consideration  of  remedies  used.     Purgatives:    Physiological 

laws  governing  their  action  142-167 

VIII.     Treatment  continued.    Remedies  employed  :  Hyoscine,  Scopo- 

lamine,  Daturine,  etc 168-198 

IX.  Treatment  continued.  Remedies  employed :  Sparteine  sul- 
phate, its  physiological  action  and  therapeutic  use 199-223 

X.  Treatment  continued.  Remedies  employed :  Gelseminine, 
Pilocarpine,  Aspirin,  Hydrochloric  acid,  Hypnotics,  Er- 
got, Quinine  by  inunction  224-234 

XL     Physical  training 235-260 

XII.     Diet  during  convalescence  and  afterward  261-274 

XIII.  Prognosis   275-284 

XIV.  Error  in  Method.    Some  reasons  for  the  past  failures  in  the 

treatment  of  morphinism 285-302 

XV.     A  plea  for  a  more  just  judgment  of  narcotic  drug  users  .  .303-323 

XVI.     Congenital    morphinism    with    report   of    cases.      Concealed 

morphinism  in  parturient  women  324-335 

(vii) 


Vlll 


Contents. 


CHAPTER  PAGE 

XVII.    The  treatment  of  acute  ailments  occurring  in  persons  addicted 

to  habitual  use  of  narcotic  drugs  336-346 

XVIII.  Review  of  Literature.  De  Quincy's  writings:  "The  Pleas- 
ures of  Opium" ;  "The  Pains  of  Opium."  Author's 
comments  347-361 

XIX.     Review  of  Literature  continued.    Erlenmeyer 362-376 

XX.     Review    of    Literature    continued.      Oscar    Jennings,    Paris, 

France.    Author's  comments  377-400 

XXI.     Review  of  Literature  continued.     American  writers :    Osier ; 

Lambert.     Author's  comment   401-424 

XXII.     Cocaine  habit.    Treatment.    Prognosis 425-433 

XXIII.  Chronic  alcoholism.     Regular  drinkers.     Periodical  alcohol- 

ism. Dipsomania.  Causes  of  alcoholism.  Moral 
cowardice.  Instability  of  character  with  bad  environ- 
ment. Bad  environment  with  ever-present  but  resisted 
appetite.  Principles  of  treatment.  Details  of  treatment. 
The  three-day  liquor  cure  (?)  434-460 

XXIV.  Chronic  alcoholism  a  disease.    Curability 461-475 

XXV.  Delirium  tremens.  Etiology.  Pathology.  Prognosis.  Treat- 
ment. Results  thus  far  obtained  476-493 

XXVI.  Treatment  of  acute  ailments  occurring  in  alcoholic  sub- 
jects   494-504 

INDEX  .505 


CHAPTER  I. 

HISTORY,  DEFINITIONS,  PATHOLOGY, 
ETIOLOGY. 

As  it  is  the  purpose  of  the  author  to  make  this  work 
one  of  an  intensely  practical  nature,  to  record  the  con- 
clusion of  the  author  based  solely  upon  his  own  clinical 
experience,  it  is  not  considered  in  harmony  with  that 
purpose  to  enter  upon  a  lengthy  historical  consideration 
of  the  uses  of  narcotic  drugs.  Suffice  it  to  say  that  the 
effects  of  the  cruder  forms  of  narcotic  drugs  were  known 
to  the  ancients,  and  these  were  used  from  time  to  time 
for  their  pain-relieving  and  hypnotic  effects;  but,  it  is 
not  believed  that  the  habitual  use  of  any  of  these  agents 
existed  to  any  considerable  extent  until  after  the  dis- 
covery of  morphine,  the  principal  alkaloid  of  opium. 

The  writings  of  DeQuincy  during  the  early  part  of 
the  last  century  doubtless  did  more  to  publish  and  to 
popularize  the  use  of  opium  than  any  other,  or  possibly 
than  all  other  influences  had  done  up  to  that  time.  His 
exaggerated  descriptions  of  the  pleasurable  effects  of 
opium  led  many  to  experiment  upon  themselves  with  it, 
and  often  these  experiments  resulted  in  complete  enslave- 
ment. These  influences,  however,  led  them  to  the  uses 
of  gum  opium,  or  liquid  preparation  made  from  it,  by 
the  mouth,  and  the  resulting  addiction  was  supposed 
to  depend  mainly  upon  a  cultivated  appetite  for  the  drug, 
spoken  of  usually  as  a  craving.  This  appetite  or  craving 
was  regarded  as  the  essential  basis  of  the  so-called  habit. 
This  was  the  accepted  view  up  to  the  time  of  Magendie. 

After  the  discovery  of  the  alkaloid  morphine  and  the 
perfection  of  the  hypodermic  syringe,  Magendie  intro- 

1  (1) 


2  Narcotic  Drug  Diseases  and  Allied  Ailments. 

duced  his  solution  of  morphine  for  hypodermic  use,  and 
among  the  other  claims  made  for  this  method  of  admin- 
istration it  was  urged  that  its  use,  hypodermically,  would 
not  produce  an  addiction,  the  theory  being  advanced  that, 
since  its  use  subcutaneously  could  not  create  an  appetite 
accompanied  by  craving  for  the  drug,  as  such,  it  did  not 
establish  an  addiction,  or,  as  it  is  erroneously  spoken  of, 
a  habit. 

Both  the  profession  and  the  faity,  in  following  these 
teachings,  found  after  it  was  too  late  that  the  hypodermic 
use  not  only  formed  an  addiction,  but  that  the  resulting 
condition  was  the  worst  form  of  addiction. 

The  author  had,  recently,  under  his  care  a  Harvard 
graduate  who,  with  a  class  of  four  others,  became  ad- 
dicted to  morphine  during  the  last  year  of  their  medical 
course,  they  having  the  assurance  of  one  of  the  faculty 
that  the  use  of  morphine  hypodermically  would  not  pro- 
duce addiction.  Four  of  this  quintet  died  prematurely, 
two  committing  suicide,  while  the  fifth  after  thirty-seven 
years  of  enslavement  was  finally  released  by  treatment. 

These  fallacious  teachings  did  much  to  increase  the 
number  of  habitual  users  of  opium,  but  aside  from  these 
influences  the  discovery  of  morphine  and  the  perfection 
of  the  hypodermic  syringe  have  been  the  greatest  factors 
in  extending  the  use  of  narcotics. 

"In  1864  the  first  case  was  reported  in  which  the 
hypodermic  injection  of  morphine  had  induced  the  condi- 
tion known  as  morphinism.  Dr.  Bertrand  was  the  first 
who  published  a  case  in  which  morphine  was  used  hypo- 
dermically, the  patient  being  the  wife  of  Dr.  Wood,  of 
Edinburgh,  who  taught  the  method  to  Dr.  Bertrand. 
Dr.  Bertrand  remarks  that  Cassargne,  in  1836,  first 
recommended  such  a  mode  of  administration  to  the  Paris 
Academy.  This  method,  however,  soon  fell  into  oblivion, 


Essential  Nature  of  Addiction. 


and  was  reintroduced  by  Dr.  Wood,  of  Edinburgh." 
("Amer.  Text  Book  of  Applied  Therapeutics.") 

It  has  only  been  during  the  last  quarter  of  a  century, 
however,  that  narcotic  addiction  has  grown  to  such  pro- 
portions as  to  attract  much  attention.  The  evil  is  now 
recognized  as  alarmingly  extensive  and  rapidly  spread- 
ing. It  is  hardly  profitable,  therefore,  at  this  time  to 
consider  farther  the  origin  and  growth  of  the  addiction. 
This  has  been  sufficiently  done  by  others. 

DEFINITIONS. 

The  term  "morphinism,"  or  morphine  disease,  is  used 
in  this  work  to  include  all  forms  of  opium  disease.  In 
fact,  it  is  intended  in  most  instances  to  be  the  equivalent 
of  narcotic  disease.  While  sixteen  alkaloids  have  been 
isolated  from  opium,  morphine  is  present  in  so  much 
larger  quantities,  and  is  so  much  more  potent  than  any 
of  the  other  alkaloids,  that  practically  all  the  medicinal 
or  narcotic  effects  of  that  drug  are  due  to  the  alkaloid 
morphine. 

Whether  the  addiction  be  to  the  habitual  use  of  crude 
opium  or  to  an  extract  or  tincture  made  from  it,  or  to 
the  active  principle,  morphine,  or  to  one  of  its  derivatives, 
the  essential  nature  of  the  ailment  is  the  same.  There- 
fore, it  is  merely  a  waste  of  time  and  unnecessary  multi- 
plication of  words  to  consider  separately  the  opium 
addiction,  the  laudanum  addiction,  the  morphine  addic- 
tion, the  codeine  addiction,  the  heroin  addiction,  etc., 
since,  no  matter  in  what  form  the  narcotic  is  used,  the 
pathology  and  treatment  are  practically  the  same. 

The  only  essential  difference  presented  by  users  of 
various  preparations  of  opium  is  in  the  time  required  for 
the  disease  to  be  confirmed,  and  in  the  prognosis.  One 
of  these  differences  is  that  codeine  and  heroin  can  be 


4  Narcotic  Drug  Diseases  and  Allied  Ailments. 

used  for  a  longer  period  without  formation  of  addiction 
than  any  of  the  other  preparations  of  opium,  and  the 
other  is  that  those  addicted  to  opium  smoking  are  more 
prone  to  relapse  after  being  cured  than  those  who  use 
opiates  in  other  forms.  With  these  two  modifications 
borne  in  mind,  the  various  forms  of  opium  disease  may 
be  considered  identical.  The  prolonged  use  of  any  drug 
the  effects  of  which  retard  excretion  of  the  products  of 
waste  results  in  the  formation  of  an  addiction,  or,  more 
correctly  speaking,  causes  a  disease. 

Other  Definitions  and  Distinction  of  Terms. — Most 
writers  on  morphinism  use  the  terms  "morphinism"  and 
"morphinomania"  interchangeably,  as  meaning  one  and 
the  same  thing.  The  author  considers  this  an  error. 
The  classes  of  persons  to  which  these  terms  should  be 
applied  differ  widely,  and  the  conditions  presented  by 
them  differ  in  etiology,  treatment,  and  prognosis ;  there- 
fore, each  of  these  terms  should  be  restricted  in  its  use 
to  the  particular  class  of  persons  to  which  it  properly 
applies. 

Morphinism  grows  out  of  the  prolonged  use  of  mor- 
phine by  a  person  of  any  type  or  character ;  no  agency, 
except  the  use  of  the  drug,  enters  into  its  production. 
Such  a  person  is  properly  spoken  of  as  a  morphinist.  In 
such  cases  the  use  of  the  drug  is  begun  for  the  relief  of 
pain;  or,  inadvertently,  without  any  element  of  dissipa- 
tion entering  into  it.  The  use  of  the  drug  is  continued 
in  such  cases  because  of  the  continuation  of  the  causal 
suffering  or  because  of  the  difficulties  involved  in  its 
renunciation.  No  mental  element  which  properly  could 
be  held  to  be  a  mania  is  present  or  contributed  in  any 
way  to  the  production  of  the  addiction  (disease).  Prob- 
ably 75  per  cent,  of  all  morphine  users  in  the  United 
States  are  morphinists. 


The  Elements  of  "Habit.' 


Morphinomania,  on  the  other  hand,  not  only  involves 
the  habitual  use  of  morphine,  as  in  the  case  of  morphin- 
ism, but  in  addition  to  that  a  mania  for  the  drug  exists. 
This  mania  may  have  arisen  from  inherited  or  acquired 
mental  and  nervous  characteristics,  or  it  may  be  the 
product  of  experiences  to  which  the  individual  was  sub- 
jected after  the  addiction  (disease)  was  formed;  but  in 
either  case  it  will  be  found  to  be  the  most  troublesome 
factor  during  treatment  and  the  one  which  will  most 
influence  the  prognosis. 

Most  emphatically  the  terms  morphinism  and  mor- 
phinomania  should  not  be  used  interchangeably ;  the  two 
classes  of  patients  differ  in  all  respects  as  greatly  as 
do  sane  and  insane  persons  suffering  from  any  other 
ailment. 

Morphine  Habit;  Opium  Habit. — The  author  con- 
siders it  very  unfortunate  that  the  terms  "morphine 
habit"  and  "opium  habit"  have  been,  and  are  still,  so 
universally  employed  when  referring  to  narcotic  addic- 
tion (disease).  They  are  misleading  and  do  not,  in  any 
wise,  accurately  describe  the  condition  present. 

Habit  implies  the  continued  repetition  of  an  act,  be- 
cause it  has  been  so  often  done  before  that  it  does  not 
require  a  new  or  repeated  exercise  of  one's  volition  to 
accomplish  it.  The  act  is  automatic  or  so  nearly  so  that 
it  does  not  require  the  conscious  act  of  the  will  to  accom- 
plish it. 

Habit  is  established  according  to  the  laws  of  the 
transmission  of  nerve  impulses.  An  impulse  in  travers- 
ing a  certain  course  meets  with  greater  resistance  the 
first  time  than  afterward.  The  oftener  it  is  repeated, 
the  less  resistance  it  meets  in  traveling  over  the  same 
path.  As  these  acts  are  frequently  repeated  the  impulse 
travels  over  this  well-worn  path  with  almost  no  resist- 


6  Narcotic  Drug  Diseases  and  Allied  Ailments. 

ance,  and  then  habit  is  fully  established,  but  all  that 
is  necessary  to  interrupt  this  course  of  action  and  sus- 
pend it  altogether  is  the  existence  or  generation  of  a 
purpose  to  have  it  arrested  and  the  exercise  of  the  will 
to  carry  out  that  purpose. 

The  exercise  of  the  will  alone  is  sufficient  to  inter- 
rupt and  suspend  any  course  of  conduct  arising  entirely 
from  force  of  habit.  That  is  not  true  of  narcotic  disease ; 
therefore,  it  is  not  a  mere  habit  and  should  not  be  spoken 
of  as  such. 

The  habitual  use  of  the  drug  is  in  response  to  an 
irresistible  demand.  That  demand  is  the  result  of  a 
toxic  diathesis  produced  by  the  administration  of  the 
drug.  The  condition  often  exists  without  any  psycho- 
logical element  entering  into  it,  and  the  patient  may  bear 
no  moral  responsibility  with  reference  to  it.  He  is  dis- 
eased, and  is  entitled  to  the  same  consideration  accorded 
victims  of  any  other  disease. 

The  repeated  administration  of  narcotic  drugs  will 
inevitably  result  in  the  demand  for  continued  and  con- 
stant use.  In  some  cases  narcotic  drugs  may  be  used 
repeatedly  with  a  greater  degree  of  safety  than  in  other 
cases,  but  this  does  not  alter  the  fact  that  the  most 
adamant  character  and  the  most  superb  physique  will 
ultimately  succumb  to  the  continued  administration  of 
narcotic  drugs  for  an  indefinitely  prolonged  period. 
Such  a  condition  cannot  with  justice  be  called  "habit"  or 
"addiction." 

The  "habit"  of  using  a  drug  is  only  a  symptom,  just 
as  the  habit  of  coughing  is  a  symptom  of  some  chronic 
ailments.  The  use  of  the  drug  produced  the  disease; 
the  disease  produced  the  habit. 

Why  are  certain  drugs  "habit"  producing  and  others 
non-"habit"  producing?  Out  of  the  discriminate  answer 


Pathology.  7 

to  this  question  comes  justice  to  the  morphine  user  and 
a  rational  conclusion  in  regard  to  therapeutic  measures 
for  the  aid  of  the  unfortunate. 

The  entire  pharmacopeia  can  be  divided  into  two 
classes:  the  "habit"-producing  drugs  and  the  non- 
"habit"-producing  drugs.  The  first  class  consists  of  the 
narcotics  and  hypnotics  or  toxic  drugs  which  render 
torpid  the  vital  functions  of  secretion  and  excretion, 
resulting  in  toxemia. 

The  non-"habit"-producing  drugs  can  be  given  re- 
peatedly and  for  prolonged  periods  without  the  for- 
mation of  "habit,"  and  their  use  can  be  discontinued 
without  discomfort.  They  do  not  lock  up  the  secretions ; 
their  use  does  not  produce  toxemia  and  does  not  result 
in  the  formation  of  "habit."  These  incontrovertible 
facts  furnish  a  key  to  the  pathogenesis  of  the  drug  habit 
as  well  as  an  index  to  the  therapeutic  measures  likely  to 
be  of  greatest  service  in  the  treatment  of  that  condition. 

PATHOLOGY. 

Much  confusion  has  existed  and  still  exists  as  to  the 
pathology  of  narcotic  addiction.  It  has  usually  been 
classed  as  a  neurosis.  Thousands  of  pages  have  been 
written,  giving  fine-spun  theories  as  to  the  possible  exist- 
ence of  some  obscure,  undefined  brain  or  nerve  lesion, 
which  would  account  for  the  symptoms  attending  the 
use  of  narcotic  drugs,  and  especially  for  the  symptoms 
which  attend  or  follow  the  withdrawal  of  narcotics  from 
those  addicted  to  their  use. 

The  resources  of  the  microscope  and  of  the  clinical 
laboratory  have  been  exhausted  in  an  effort  to  demon- 
strate the  presence  of  such  a  structural  lesion,  but  with- 
out avail.  The  only  structural  lesions  that  have  been 
demonstrated  in  these  conditions  are  the  changes  in  the 


8  Narcotic  Drug  Diseases  and  Allied  Ailments. 

blood,  and  these  do  not  differ  from  those  existing  in 
other  anemic  conditions.  Most  medical  writers,  not  ac- 
cepting these  fine-spun  theories  of  neurologists,  dismiss 
this  part  of  their  subject  with  the  statement  that  the 
pathology  is  nil. 

The  structural  pathologists,  those  who  insist  that 
every  pathological  condition  is  the  result  of  a  structural 
lesion,  have  had  the  ear  of  the  profession,  and  have  so 
dominated  professional  opinion  during  the  last  half- 
century,  that  few  men  have  been  bold  enough  to  insist 
that  a  real  pathological  condition  could  exist  without  an 
underlying  or  attending  structural  lesion. 

During  the  last  few  years,  however,  professional 
opinion  has  undergone  a  considerable  change  and  it  is 
not  at  this  time  considered  lese-majesty  to  say  that  a 
disease  may  be  purely  functional  and  yet  be  of  such 
gravity  as  not  only  to  require  active  treatment,  but  to 
cause  death,  if  not  so  treated. 

Those  who  have  studied  the  subject  have  been  con- 
fronted by  conditions  which  they  have  interpreted  in 
divers  ways,  but  in  their  efforts  to  reason  backward  from 
effect  to  cause  they  have  been  lost  in  the  hazy  marsh  of 
superstition  as  completely  as  those  who  wrote  on  malaria 
and  yellow  fever  a  generation  ago.  Their  bewilderment 
was  increased  and  the  truth  longer  concealed  by  the 
dogmatic  teaching  of  structural  pathologists. 

Writers  on  drug  addiction  (disease),  being  guided 
by  such  teachings,  have  striven  in  every  way  to  demon- 
strate a  structural  lesion  in  drug  addiction.  Every 
structure  of  the  body  has  been  minutely  examined,  but 
the  microscope  has  steadily  refused  to  verify  the  pres- 
ence of  any  lesion  which  would  account  for  the  conditions 
present.  The  manifestations  which  were  most  promi- 
nent being  of  a  nervous  character,  some  obscure  lesion 


Erroneous  Views  of  Pathology. 


of  the  nervous  system  has  been  supposed  to  exist,  but  no 
one  has  been  able  to  demonstrate  its  presence. 

At  this  point,  writers  have  diverged  in  their  views. 
Some,  while  being  unable  to  demonstrate  the  presence 
of  a  structural  pathology,  have  still  held  that  it  did  exist, 
and  that  this  obscure,  undennable,  undemonstrable  lesion 
was  the  cause  of  all  the  manifestations  of  disease  seen  in 
these  cases.  Being  uncertain  as  to  pathology,  their 
suggestions  as  to  treatment  were  as  full  of  unreason  and 
superstition  as  their  views  of  pathology  were  vague. 
They,  however,  took  refuge  in  a  generic  term,  neurosis, 
and  classed  these  addictions  as  such  and  advised  symp- 
tomatic treatment. 

The  nervous  manifestations  presented  in  these  cases 
were  so  nearly  innumerable  and  so  mystifying  that  the 
practical  man  who  attempted  to  treat  a  patient  of  this 
class  symptomatically  soon  found  himself  in  deep  water, 
and  very  shortly  would  throw  up  his  hands  in  horror  and 
cry  out  with  Da  Costa  and  others,  "There  is  no  remedy 
for  the  opiate  habit,"  and  "There  is  no  help  for  the 
widow's  son."  Those  who  held  the  views  of  writers  of 
this  class,  practically,  gave  up  these  cases  as  hopelessly 
incurable. 

Other  writers,  more  materialistic,  but  less  consistent, 
not  recognizing  any  other  than  a  structural  pathology 
for  disease,  and  being  unable  to  demonstrate  the  presence 
of  a  structural  lesion  in  narcotic  addiction  (disease), 
took  the  position  that  there  was  no  pathology.  Writers 
of  this  class  dismiss  that  part  of  the  subject  with  a 
sweeping  statement  couched  in  four  words,  "The  pathol- 
ogy is  nil" 

These  writers,  however,  were  still  confronted  with 
the  manifestations  attending  the  uses  of  narcotic  drugs. 
They  were  still  confronted  by  living  facts  for  which  they 


10  Narcotic  Drug  Diseases  and  Allied  Ailments. 

must  account  in  some  way.  In  an  effort  to  escape  from 
this  dilemma  they  took  refuge  in  the  word  "vice."  They 
therefore  classed  narcotic-drug  addiction  as  a  mere  vice, 
a  perversion  of  the  will,  a  degenerate  state  into  which  the 
victim  entered  from  choice,  claiming  that  in  pursuing 
such  a  course  he  was  prompted  or  led  by  inherited  or  ac- 
quired degeneracy,  asserting  that  all  who  fell  into  the 
use  of  narcotic  drugs  were,  primarily,  neurotic  weaklings 
who,  by  yielding  to  the  influence  of  the  drug,  had  been 
made  doubly  unreliable.  They  made  free  use  of  such 
terms  as  "perverts,"  "fiends,"  "inveterate  liars,"  etc., 
and  classed  every  drug  user  as  one  who  had  willfully 
yielded  his  God-given  powers  of  self-control,  and  volun- 
tarily accepted  the  dominion  of  a  mere  vice.  These  views 
are  not  tenable. 

While  it  is  true  that  many  nervous  manifestations 
attend  the  use  of  narcotics,  and  especially  the  disuse 
of  narcotics  by  those  who  are  habituated  to  their  use, 
still  the  condition  is  not  in  any  sense  a  true  neurosis; 
but  it  is  purely  and  solely  a  toxemia,  and  as  such  it 
belongs  to  the  field  of  internal  medicine  and  not  to 
neurology. 

The  author  is  aware  that  this  classification  will  be 
objected  to,  but  it  is  confidently  believed  that  before  this 
treatise  shall  have  been  completed  the  evidence  produced 
will  be  such  as  to  sustain  his  position. 

There  is  as  much  reason  to  classify  typhoid  fever  as  a 
neurosis  as  there  is  to  classify  narcotic-drug  addiction 
(disease)  as  such.  The  exaggerated  nervous  condition 
manifested  by  typhoid  patients  is  equally  as  marked  as 
that  seen  in  drug  addiction,  yet  we  know  that  typhoid 
fever  is  an  infection  and  a  toxemia  combined. 

More  than  ten  years  ago  the  author  reached  the  con- 
clusion that  the  essential  pathology  of  narcotic-drug  ad- 


Suffering  from  Withdrawal,  Avoidable.  11 

diction  (disease)  is  a  toxemia,  a  toxemia  of  drug,  auto-, 
and  intestinal  origin. 

This  view  was  the  outcome  of  the  study  and  treat- 
ment of  about  150  drug  patients.  But,  while  the  proposi- 
tion was  then  announced,  its  full  significance  was  not 
really  comprehended.  Clinical  observation  made  during 
the  treatment  of  more  than  3000  patients  of  this  class 
since  that  time  has  given  the  author  ample  opportunity 
to  verify,  in  every  detail,  the  claim  then  made. 

The  author  feels  fully  warranted  in  saying  that  every 
symptom  attendant  upon  the  use  or  the  disuse  of  a 
narcotic  drug  is  the  direct  outcome  of  drug,  auto-,  and 
intestinal  toxemia.  Just  in  proportion  to  which  the  toxic 
condition  of  the  system  is  overcome,  all  these  nervous 
manifestations  disappear. 

It  is  the  belief  of  the  author  that  if  a  drug  patient 
could  be  made  cell  clean,  that  is,  if  every  cell  and  struc- 
ture of  the  body  could  be  entirely  freed  from  toxic 
matter,  there  would  be  no  nervous  manifestations  or 
suffering  incident  to  or  following  the  withdrawal  of 
narcotics  from  an  habitue. 

It  is  impossible  to  perfectly  cleanse  the  system  of  a 
drug  user,  so  long  as  any  quantity  of  the  drug  is  taken. 
Still,  the  nearer  this  ideal  condition  is  approached,  the 
less  suffering  accompanies  or  follows  the  withdrawal  of 
the  opiate. 

While  we  have  been  unable,  by  laboratory  methods, 
to  demonstrate  the  pathology  of  morphinism,  we  have 
reached  the  conclusion  by  clinical  experience,  acquired  in 
handling  a  wide  and  varied  series  of  narcotic  patients, 
that  this  view  of  the  pathology  is  unquestionably  correct. 
In  such  circumstances  as  this,  where  we  have  not  the 
data  to  enable  us  to  reason  from  cause  to  effect,  the  most 
practical  mode  open  to  us  of  studying  such  questions,  is 
to  reason  backward  from  effect  to  cause. 


12  Narcotic  Drug  Diseases  and  Allied  Ailments. 

If  in  pursuing  this  course  with  reference  to  the 
pathology  of  narcotic-drug  addiction  (disease),  we  take 
up  the  impressions  made  by  the  narcotic  on  the  system 
and  analyze  them,  we  find  the  following  conditions  to 
exist :  The  first  dose  of  morphine  brings  about  a  state 
of  quietude  or  torpor  which  is  soon  succeeded  by  sleep, 
accompanied  by  diminished  or  completely  arrested  peri- 
staltic action.  This  is  followed  by  constipation,  with 
reduced  activity  of  all  the  secreting  and  excreting  glands. 
In  the  course  of  from  eight  to  twelve  hours  the  hypnotic 
effect  and  most  of  the  other  effects  have  subsided,  and 
the  functional  activity  of  the  system  has  become  normal, 
and  possibly  secretion  and  excretion  are  carried  on  at  a 
slightly  accelerated  rate ;  but  it  requires  several  days  for 
this  increased  activity  of  the  excreting  organs  to  free 
the  system  from  the  products  of  wastes  which  should 
have  been  eliminated  during  the  time  these  func- 
tions were  retarded  by  the  benumbing  influence  of  the 
narcotic. 

Now,  if  before  that  is  accomplished  another  dose  of 
the  drug  is  taken,  the  eliminating  organs  are  again  inter- 
fered with  in  their  work,  and  if  this  is  repeated  from  day 
to  day  the  system  soon  becomes  surcharged  with  the 
products  of  tissue  disintegration  and  their  fermentative 
compound. 

These  waste  products  play  a  much  more  important 
role  in  causing  the  difficult  complications  met  upon  the 
withdrawal  of  morphine,  known  as  abstinence  symp- 
toms, than  does  the  drug  itself.  After  the  use  of  the 
drug  is  kept  up  for  a  time,  upon  examination  of  the 
patient,  we  find  the  skin  dry  and  crusty,  the  tongue 
coated,  breath  foul,  bowels  habitually  constipated,  diges- 
tion impaired,  heart  action  defective,  and  other  evidences 
of  portal  engorgement. 


Symptoms  Incident  to   Withdrawal. 


13 


When  the  administration  of  the  drug  is  discontinued 
and  the  patient  is  allowed  to  go  for  a  time  without  it, 
some  of  these  symptoms  give  way  to  others  of  a  different 
character,  while  others  of  them  are  merely  intensified, 
but  not  changed  in  character.  The  dry  skin  gives  way  to 
excessive  sweating,  the  constipation  to  diarrhea,  colic, 
nausea,  and  other  evidence  of  gastrointestinal  disorder. 
With  this  clinical  picture  before  us,  we  could  arrive  at 
no  other  conclusion  but  that  the  patient's  system  was 
intensely  saturated  with  toxins  of  intestinal  and  auto- 
origin. 

With  toxins  existing  in  the  system  to  the  degree  in- 
dicated by  this  clinical  picture,  we  should  have  no  diffi- 
culty in  accounting  for  the  perverted  functional  activity 
of  every  organ  in  the  body,  as  well  as  for  the  various 
and  sundry  nervous  manifestations  incident  to  the  with- 
drawal of  the  drug.  So  long  as  the  drug  is  taken  at 
regular  intervals,  in  the  accustomed  dose,  the  nerve 
centers  are  kept  benumbed  so  as  not  to  be  responsive  to 
the  irritating  effects  of  this  toxic  accumulation.  But  if 
the  drug  is  withheld  in  whole  or  in  part  the  nervous 
system  soon  becomes  sensitive  and  therefore  responsive 
to  toxic  irritation,  and  various  functional  derangements 
are  at  once  apparent. 

Among  the  early  symptoms  incident  to  the  with- 
drawal is  a  slight  rising  of  temperature,  and  as  the  hours 
following  the  withdrawal  of  the  drug  pass  this  tempera- 
ture rise  increases,  and  if  left  uncontrolled  will  run  to 
very  high  degrees.  This  fever  is  accompanied  by  the 
most  intense  aching  of  the  bones,  limbs,  and  in  fact  every 
part  of  the  body  is  in  more  or  less  discomfort.  Every 
nerve  in  the  body  seems  to  be  on  the  outside  and  as  if  it 
were  being  lacerated  by  some  instrument  of  torture. 

Appearing  about  the  same  time  as  the  beginning  of 
this  rise  of  temperature  can  be  noted  a  zone  of.  uneasiness 


14  Narcotic  Drug  Diseases  and  Allied  Ailments. 

about  the  umbilicus,  known  as  colic.  This  increases  as 
the  system  becomes  less  and  less  under  the  influence  of 
the  drug  until  the  pain  is  distressing.  The  heart  action 
grows  much  more  rapid  and  the  pulse  is  small  and  jerky. 
This  difficult  heart  action  is  usually  attended  by  excessive 
sweating,  intermittent  in  type,  resembling  to  some  extent 
intermittent  fever,  that  is,  the  skin  will  be  dry  and  there 
will  be  an  abrupt  rise  of  temperature  due  to  the  irritative 
effects  of  the  toxins,  and  this  seems  to  overpower  the 
heart  and  the  circulation  becomes  deficient,  and  then  the 
body  soon  becomes  bathed  in  a  cold,  clammy  sweat, 
during  which  there  is  a  recession  of  the  fever. 

Nausea  and  vomiting  usually  precede  or  appear 
synchronously  with  the  excessive  diaphoresis  and  per- 
sistently continue  until  some  relief  of  the  engorged 
condition  of  the  gastrointestinal  system  is  effected.  If 
diarrhea  sets  in,  the  nausea  will  not  be  so  marked,  but  so 
long  as  the  bowel  is  not  moving  freely  the  vomiting  con- 
tinues and  often  becomes  stercoraceous. 

The  suffering  of  the  patient  under  such  circum- 
stances is  extreme,  and  it  could  not  be  expected  that  one 
would  stand  so  intense  suffering  without  doing  anything 
in  his  power  to  obtain  relief.  This  urgent  physical 
demand  for  the  quieting  effects  of  the  narcotic  has  been 
interpreted  as  being  a  mania  for  the  drug,  but  it  should 
not  be  so  classed. 

These  symptoms  have  a  real  physical  basis. 

In  examining  more  minutely  into  the  condition  of  the 
various  organs  we  find  that  the  activity  of  the  liver  and 
intestinal  glands  is  diminished.  The  rhythmic  motion  of 
the  intestines  is  suspended,  alvine  dejections  are  arrested, 
and  the  excretion  of  urea  is  slightly  decreased. 

The  effects  of  the  drug,  continually  used,  result  in 
the  retention  of  a  large  percentage  of  the  products  of 


Influence  of  Narcotics  on  Intellect.  15 

tissue  waste.  The  presence  of  this  excrementitious 
matter  in  the  system  leads  to  the  formation  of  ptomaines 
and  other  ferments,  digestion  and  assimilation  are 
thereby  much  impaired,  and  the  victim  soon  becomes 
intensely  self-poisoned  and,  later,  profoundly  anemic. 

The  nervous  system  under  the  constant  influence  of 
this  toxic  matter  becomes  unsteady  and  irritable,  and  in 
a  short  time  the  patient  presents  a  picture  of  an  aged, 
neurotic,  anemic  wreck. 

From  a  grosser  anatomical  standpoint,  no  structural 
lesions  result  from  the  prolonged  use  of  opiates,  but  a 
careful  physical  examination  reveals  unmistakable  evi- 
dence of  the  most  widespread  functional  derangements : 
the  blood  is  thin  and  deficient  in  the  oxygen-carrying  red 
corpuscles;  the  mucous  membranes  are  pale, — in  fact, 
all  the  structures  show  signs  of  profound  anemia;  the 
abdomen  is  full  and  unduly  indurated;  the  liver  is  en- 
larged and  the  portal  system  engorged;  tongue  coated; 
breath  foul;  skin  alternately  dry  or  excessively  active, 
but  always  swarthy  and  yellow;  heart  action  variable, 
depending  upon  the  stage  of  narcotic  impression; 
nervous  reflexes  either  blunted  or  exaggerated;  the 
muscles  are  flabby  and  relaxed ;  the  memory  is  impaired ; 
mind  inactive,  and  the  entire  bearing  of  the  patient  is 
one  of  dejection  and  hopelessness. 

To  sum  up,  the  evidence  clearly  indicates  a  condition 
of  intense  intoxication,  with  profound  anemia,  attended 
by  derangement  of  the  nervous  system  and  impaired 
mentality. 

The  powers  of  perception  are  materially  blunted,  and 
actions  based  on  perception  may  not  represent  the  real 
intent  of  the  individual,  because  erroneous  conclusions 
are  likely  to  be  drawn  from  these  impressions;  actions 
based  upon  such  conclusions  would  be  correspondingly 


16  Narcotic  Drug  Diseases  and  Allied  Ailments. 

erroneous  or  untrue  to  the  real  intent  of  the  individual, 
but  actions  arising  from  a  concept  do  usually  represent 
the  real  purposes  of  the  individual. 

A  person  in  such  condition  is  unable  to  acquire  new 
facts  for  the  reason  that  the  perceptive  faculties — in  fact, 
the  entire  nervous  system — are  so  blunted  that  impres- 
sions coming  from  without  are  not  distinctly  perceived, 
and,  as  these  are  received  in  a  blurred  and  indistinct 
manner,  they  are  not  registered  with  such  completeness 
as  to  be  recalled  accurately  by  a  future  effort  of  the  mem- 
ory. It  is  almost  out  of  the  question  for  one  in  this  con- 
dition to  memorize  any  composition,  or  to  recall  with 
perfect  accuracy  impressions  received  from  without. 

This  defect,  or  inability  to  reproduce  accurately 
impressions  received  from  without,  has  done  much  to 
create  the  impression  that  all  drug  habitues  are  notori- 
ously untruthful.  This,  as  applied  to  many  of  them,  is 
an  unjust  accusation. 

It  is  true  that  many  drug  habitues  do  not  make  any 
approach  to  truthfulness,  but,  when  the  influences  under 
which  this  state  of  affairs  has  developed  are  considered, 
it  will  be  found  that  many  influences  other  than  the 
effects  of  the  drug  itself  have  contributed  to  the  develop- 
ment of  their  untruthful  habits.  This  phase  of  the  sub- 
ject, however,  will  be  more  fully  considered  in  a  later 
chapter  of  this  work. 

The  most  satisfactory  evidence  of  the  correctness  of 
the  views  of  the  pathology  of  narcotic  addiction  (dis- 
ease), herein  stated,  will  be  found  in  the  results  of  the 
treatment  based  on  such  views.  This  evidence  will  be 
presented  in  detail  in  the  chapters  on  Treatment. 

If  the  long  sought  for  brain  or  nerve  lesion  exists  as 
a  pathological  factor  in  these  cases  all  evidence  of 
its  existence  certainly  disappears  under  rational  treat- 


Etiology.  17 

ment  based  upon  the  pathology  herein  denned.  Since 
the  cure  of  the  patient  is  the  object  of  this  study,  and 
since  this  is  accomplished  by  treatment  based  on  the 
views  herein  stated,  the  author  has  no  inclination  to 
enter  into  a  "hair-splitting"  discussion  as  to  the  possibili- 
ties of  the  existence  of  a  disease  without  an  underlying 
structural  lesion. 

ETIOLOGY. 

The  alarming  rate  at  which  the  habitual  use  of  nar- 
cotic drugs  has  increased  during  the  last  four  decades  is 
a  matter  which  should  give  us  the  deepest  concern.  Two 
or  three  factors  have  contributed  to  this  result.  The 
first  and  most  important  is  the  popularizing  of  the  hypo- 
dermic syringe  which  has  occurred  during  that  time. 

Before  the  introduction  of  the  hypodermic  syringe, 
people  had  not  been  taught  to  expect  immediate  relief 
as  soon  as  the  physician  arrived.  Then,  the  physician 
was  free  to  administer  such  remedies  as  were  indicated, 
and  the  patient  had  no  other  idea  than  that  he  must  wait 
a  reasonable  time  for  relief  from  them. 

But  during  recent  years  the  people  have  been  taught 
to  expect  relief  from  pain  as  soon  as  the  physician  arrives. 
They  understand  that  he  can  give  a  hypodermic  dose 
and  immediate  arrest  of  pain  will  follow.  This  demand 
is  so  urgent  and  universal  that  many  physicians  fail  to 
withstand  it.  Every  physician  understands  that  if  he 
refuses  to  yield,  another  may  be  called  in  his  stead  who 
will  do  so.  As  he  does  not  wish  to  surrender  his  case 
to  a  competitor,  he  feels  almost  compelled  to  comply  with 
the  demand  of  the  patient  or  his  friends  for  immediate 
relief.  He  gives  the  soothing  potion,  and  thus  unwit- 
tingly contributes  his  moiety  to  the  education  of  the 
public  in  the  wrong  direction. 


18  Narcotic  Drug  Diseases  and  Allied  Ailments. 

Should  the  patient's  ailment  be  a  chronic  and  painful 
one,  the  repetition  of  these  doses  often  leads  to  complete 
enslavement.  A  majority  of  the  victims  of  narcotic 
drugs  among  the  laity  trace  their  addiction  to  the  admin- 
istration of  drugs  by  a  physician. 

It  should  be  a  universal  rule,  however,  among  physi- 
cians to  use  an  opiate  only  where  one  or  two  doses  will 
suffice.  When  the  ailment  is  a  chronic  painful  one  it  is 
worse  than  folly  to  begin  to  relieve  that  pain  with  an 
opiate.  This  should  not  be  done,  not  only  because  it 
generally  leads  to  enslavement,  but  because  it  is  not  a 
curative  treatment.  On  the  contrary,  opiates  check 
secretion,  and  therefore  perpetuate  and  aggravate  any 
existing  painful  ailment. 

But,  so  long  as  people  imperatively  insist  on  being 
given  relief  as  soon  as  the  physician  reaches  the  house, 
patients  will  be  called  upon  to  suffer  the  consequences  of 
their  unreasonable  demand. 

Conditions  which  predispose  to  the  use  of  narcotics 
may  be  either  physical,  mental,  moral,  or  accidental. 
The  time  required  to  develop  a  confirmed  addiction  (dis- 
ease) varies  greatly  in  different  individuals;  but,  it  may 
be  said  with  certainty  that  any  human  being  will  become 
addicted  to  opiates  if  these  are  used  continuously  for  any 
considerable  length  of  time. 

In  the  average  Caucasian  thirty  days'  daily  use  is 
enough  to  establish  the  addiction  (disease)  to  such  a 
degree  that  very  few  persons  would  be  able  to  extricate 
themselves  from  it  by  their  own  efforts.  If  the  daily  use 
be  continued  as  much  as  three  or  four  months,  it  is 
almost  impossible  for  one  to  stop  its  use  without  active 
treatment.  A  few  persons,  usually  women,  have  used 
an  opiate  as  much  as  four  to  six  months  and  then  volun- 
tarily given  it  up  without  aid  from  others.  But,  while 


Various  Ailments  Leading  to  Addiction.  19 

one  succeeds  in  such  an  undertaking,  hundreds,  and  even 
thousands,  fail. 

Among  the  physical  ailments  which  have  contributed 
largely  to  the  formation  of  a  drug  addiction  (disease), 
we  mention  chronic  rheumatism,  migraine,  hepatic  and 
renal  colic,  asthma,  chronic  dysentery,  hookworm,  pella- 
gra, threatened  abortion,  tuberculosis,  cancer;  alcohol- 
ism, especially  periodic  alcoholism;  unstable  nervous 
organizations,  other  painful  ailments,  autointoxication, 
exhaustion,  overwork. 

The  use  of  opiates  in  such  ailments  as  chronic 
rheumatism  and  migraine  should  never  be  thought  of. 
Rheumatism,  if  not  due  to,  is  certainly  intensified  by, 
toxins  produced  in  the  system.  Opiates  make  the 
elimination  of  these  products  more  difficult  and,  there- 
fore, necessarily  increase  rheumatic  symptoms.  The 
same  may  be  said  of  migraine  and  asthma.  While  a 
single  dose  of  morphine  gives  the  most  prompt  relief,  it 
is  a  dangerous  thing  to  allow  the  patient  to  know  a  drug 
of  this  character  is  being  given  him,  as  he  is  too  liable 
to  secure  and  take  that  drug  without  calling  a  physician 
and,  therefore,  too  frequently,  and  is  very  liable  to  be- 
come addicted  to  the  use  of  it. 

Chronic  dysentery  is  one  ailment  in  which  an  opiate 
is  frequently  helpful  and,  if  used  to  a  limited  extent, 
would  be  justifiable;  but,  it  must  be  remembered  that 
merely  checking  the  bowel  does  not  cure  the  ailment. 

The  use  of  opiates  for  the  relief  of  hepatic  and  renal 
colic  is  justifiable.  These  ailments  are  of  such  extremely 
painful  nature  and  are  usually  of  such  short  duration 
that  a  few  doses  of  opium  are  sufficient  to  tide  the  patient 
over  one  of  the  acute  attacks. 

Not  only  so,  but  an  opiate  is  really  curative  in  these 
attacks,  that  is,  it  is  curative  in  the  sense  that  it  aids  in 


20  Narcotic  Drug  Diseases  and  Allied  Ailments. 

cutting  short  the  acute  attack  of  colic.  By  relieving  pain 
and  rendering  less  sensitive  the  nerves  in  the  duct  in 
which  the  missile  is  lodged,  the  chronic  state  of  spasms 
is  overcome,  and  this  will  often  allow  the  duct  to  dilate 
to  such  an  extent  as  to  admit  of  the  passage  of  the  stone 
which  is  causing  the  pain.  While  opium  is  not  the  best 
agent  for  this  purpose,  it  is  one  that  does  give  relief, 
and  shortens  the  attack. 

About  the  only  chronic  ailment  in  which  the  author 
would  justify  the  use  of  opiates  is  in  cancer  after  it  has 
passed  the  operable  stage.  When  it  is  seen  that  the 
patient  cannot  be  cured,  then  the  physician  should  give 
him  anything  that  will  contribute  to  his  comfort  during 
the  time  he  must  remain  alive.  For  this  purpose  the 
free  use  of  opiates  is  justifiable  even  if  confirmed  addic- 
tion should  be  established  by  it. 

In  such  cases  the  patient's  life  can  be  prolonged  only 
for  a  short  time,  and  the  fact  that  he  must  use  an  opiate 
every  day  does  not  materially  injure  him,  and  if  it  gives 
him  some  comfort  he  is  entitled  to  it.  Therefore,  with- 
out regard  to  the  formation  of  the  addiction  the  opiate 
should  be  given  as  freely  as  his  condition  demands.  In 
all  other  chronic  painful  ailments  the  use  of  opiates 
should  be  avoided. 

Inordinate  ambition,  overwork,  and  insufficient  rest 
have  been  the  cause,  however,  of  a  very  large  percentage 
of  addictions,  especially  among  medical  men. 

Among  the  mental  and  moral  conditions  predisposing 
to  the  formation  of  narcotic-drug  addiction,  we  might 
mention  lack  of  conviction,  low  ideals,  moral  cowardice, 
self-centered  life,  softness,  overindulgence  by  parents, 
indifference  to  the  obligations  common  to  all  humanity, 
living  for  the  gratification  of  the  present  moment,  low 
and  inadequate  views  as  to  the  meaning,  or  obligations, 
of  life,  overconfidence,  and  inordinate  ambition. 


Defects  of  Character  Lead  to  Addiction.  21 

Instability  of  character  with  deficient  convictions  are 
important  defects  in  anyone,  and  expose  such  a  one  to 
many  dangers  as  he  passes  through  life.  The  man  with 
positive  traits  of  character,  fixed  habits,  and  strong  con- 
victions as  to  what  is  right  and  wrong,  and  who  has  a 
keen  sense  of  his  obligation  to  humanity,  will,  by  the 
mere  possession  of  these  opinions  and  convictions,  be 
protected  from  many  of  the  snares  and  pitfalls  that 
inevitably  await  those  who  are  less  fixed  in  their  habits 
and  convictions. 

If  the  purposes  and  conduct  of  those  who  take  up 
the  use  of  narcotic  as  a  dissipation  be  analyzed,  it  will 
be  found  that  selfishness  lies  at  the  center  of  most  of 
their  actions;  in  fact,  their  lives  are  self-centered. 
Everything  points  to  something  for  themselves.  They 
live  for  the  gratification  of  the  present  moment,  almost 
exclusively. 

Persons  of  this  type  have  so  little  moral  purpose, 
so  little  kindness,  and  so  little  care  for  anything  but 
themselves  that  they  are  unwilling  to  suffer  even  for  one 
moment.  If  the  slightest  ailment  occurs  they  consider 
it  the  most  important  thing  in  life,  and  as  it  affects  them 
it  appears  to  them  to  be  a  mountain  and  must  be  relieved 
at  once  at  all  hazards.  This  exalted  estimation  of  their 
own  personality  leads  them  into  many  errors,  as  well 
as  many  dangers. 

If  it  happens  that  they  are  attacked  by  a  painful 
ailment  of  any  kind,  their  urgent  insistence  upon  imme- 
diate relief  at  all  hazards  leads  almost  inevitably  to  drug 
slavery.  Opiates  have  a  very  seductive  effect  on  such 
persons.  They  are  usually  out  of  harmony  with  them- 
selves and  everything  surrounding  them.  The  effects 
of  opium  relieve  this  discordant  condition  and  bring 
them  somewhat  into  harmony  with  their  environments, 


22  Narcotic  Drug  Diseases  and  Allied  Ailments. 

and  to  them  this  is  a  most  delightful  experience.  They 
are,  therefore,  very  prone  to  fall  a  victim  to  narcotic 
drugs. 

Among  the  accidental  causes  which  lead  to  the  for- 
mation of  narcotic  addiction  is  the  use  of  proprietary 
medicines.  Prior  to  the  enactment  of  the  Pure  Food 
Law  nostrums  were  put  up  without  formulae,  or  other 
evidence  of  their  composition,  but  recommended  for 
various  ailments.  Many  of  these  preparations  contained 
narcotics  in  sufficient  quantities  to  establish  an  addiction 
in  a  short  time.  The  cough  mixtures,  the  consumptive 
cures,  the  asthma  cures,  etc.,  almost  all  contained  opiates, 
and  if  used  for  any  considerable  length  of  time  an  addic- 
tion resulted. 

These  compounds  were  used,  as  a  rule,  without  the 
knowledge  on  the  part  of  the  person  using  them  that  they 
contained  an  opiate;  therefore,  an  addiction  resulting 
from  their  use  was  purely  accidental.  That  is,  there  was 
no  purpose  on  the  part  of  the  individual  to  take  the  opiate 
and,  therefore,  no  moral  guilt  or  responsibility  entered 
into  the  formation  of  the  addiction. 

Again,  one  who  is  afflicted  with  some  painful  ailment 
and  under  the  care  of  a  physician,  and  that  physician 
administers  to  him  an  opiate  for  a  prolonged  period  with- 
out the  patient  knowing  what  he  is  taking,  he  is  thus, 
day  by  day,  being  entrapped  into  a  web  that  may  enslave 
him  for  life.  One  who  becomes  addicted  under  such 
circumstances  is  not  in  any  wise  to  blame. 

Physicians  have  not  understood  the  danger  of  this 
course  and  frequently  will  give  opiates  to  patients  for 
several  months  until  a  painful  ailment  has  subsided,  then 
discharge  them  with  the  advice  that  they  do  not  need 
further  treatment.  This  leaves  the  patient  to  fight  out 
the  battle  for  freedom  without  the  aid  and  direction  of 


Addiction  Results  from  Any  Narcotic.  23 

the  proper  advisor.  If  the  patient  has  become  aware  of 
the  fact  that  an  opiate  was  what  was  being  given  him, 
he  will  almost  certainly  secure  a  supply  and  continue  to 
use  it,  notwithstanding  the  physician's  advice  that  it 
must  be  stopped.  This  is  the  true  history  of  addiction 
in  many  cases. 

The  length  of  time  which  an  opiate  may  be  taken 
before  addiction  is  confirmed — the  disease  really  estab- 
lished— depends  not  only  upon  the  peculiarities  of  the 
persons  themselves,  but  also  upon  the  manner  in  which 
the  opiate  is  taken  and  on  the  preparation  of  the  opiate 
taken. 

Crude  opium  and  laudanum  taken  by  the  mouth  are 
absorbed  more  slowly  than  the  other  preparations  of 
opium  and,  therefore,  the  narcotic  impression  is  not  as 
pronounced  at  any  stage  of  the  effect.  These  can  be 
taken,  in  this  manner,  for  a  longer  period  than  morphine 
could  be  taken,  without  forming  an  addiction. 

Morphine  can  also  be  taken  by  the  mouth  for  some- 
what longer  periods  without  forming  a  confirmed  addic- 
tion than  it  can  be  when  used  hypodermically.  The 
hypodermic  use  brings  about  a  very  prompt  and  pro- 
found impression,  and  all  the  secretory  and  excretory 
organs  are  greatly  restricted  in  their  action.  This  re- 
tardation of  excretion  causes  the  rapid  development  of 
the  toxic  condition  upon  which  confirm  addiction  rests. 

Codeine  and  heroin,  on  the  other  hand,  check  secre- 
tion less  than  any  other  forms  of  opium,  and  because 
of  that  fact  they  do  not  cause  such  rapid  intestinal 
and  auto  toxemia.  They  can  be  taken  or  given  for  a 
longer  time  than  any  other  form  of  opiate  without  estab- 
lishing a  confirmed  addiction. 

But,  any  narcotic  taken  habitually  will  form  a  con- 
firmed addiction  (disease).  In  this  list  we  must  include, 


24  Narcotic  Drug  Diseases  and  Allied  Ailments. 

in  addition  to  opium  and  its  derivatives,  chloral,  chloro- 
form, atropine,  hyoscine,  scopolamine, — in  fact,  all  of 
the  belladonna  series  of  active  principles.  All  these  are 
narcotic  in  their  effect;  they  all  check  secretion,  and, 
therefore,  bring  about  the  toxic  condition  which  is,  in 
fact,  the  essential  pathology  of  the  narcotic  disease,  and 
all  drugs  which  retard  the  excretion  of  the  products  of 
waste  will,  if  taken  a  sufficient  length  of  time,  result  in 
addiction  (disease). 

Many  of  the  members  of  our  own  profession  are  fall- 
ing victims  to  drugs  also.  The  use  of  narcotics  has  in- 
creased even  more  rapidly  among  the  profession  than 
among  the  laity. 

It  would  seem  that,  of  all  persons,  the  physician 
should  be  the  last  to  fall  into  such  a  snare ;  that  his  pro- 
fessional training,  his  knowledge  of  the  evil  consequences 
of  the  use  of  narcotics,  should  effectively  fortify  him 
against  their  use.  The  facts,  however,  do  not  bear  out 
that  idea. 

A  much  larger  percentage  of  physicians  is  addicted 
to  drugs  than  is  found  among  members  of  any  other 
profession  or  calling.  Let  us  see  if  we  can  reach  some 
rational  conclusion  as  to  why  this  is  the  case. 

Unfortunately,  many  persons  enter  the  profession  of 
medicine,  as  they  enter  other  callings,  without  definitely 
fixed  convictions  upon  fundamental  questions.  In  the 
life  of  every  man  there  should  be  a  few  questions,  at 
least,  which  are  settled  for  all  time  to  come. 

Among  these  should  be  his  accountability  to  his 
Creator,  loyalty  to  the  flag  of  his  country,  confidence  in 
the  honor  of  his  father  and  the  virtue  of  his  mother, 
and  his  determination  to  maintain  his  own  fidelity  to  his 
wife.  These  questions  should  be  so  fully  settled  as  not 
to  be  open  to  debate  even  with  himself. 


Progressive  Steps  in  Formation   of  Addiction.  25 

For  one  entering  upon  the  practice  of  medicine,  the 
author  would  add  to  this  a  fixed  conviction  that  one  who 
lives  by  his  brain  must  not  work  under  stimulation,  that 
he  cannot  afford  to  lengthen  his  working  hours  by  the 
use  of  stimulants. 

One  entering  the  profession  without  definite  convic- 
tions on  this  point  allows  circumstances  to  dictate  his 
course.  If  he  is  well  qualified  and  energetic,  and  settles 
in  a  community  where  his  services  are  in  demand,  in  a 
few  years  he  builds  up  a  practice  which  taxes  his 
strength.  Coming  in  after  a  full  day's  work  he  finds 
other  calls  awaiting  him.  He  is  tired — in  fact,  his 
strength  is  exhausted,  and  he  should  not  undertake  more, 
but  he  reasons  that  some  of  these  calls  are  from  people 
whom  he  cannot  afford  to  turn  away,  that  he  must 
answer  them. 

In  order  to  whip  up  his  flagging  energies  so  as  to 
enable  him  to  meet  these  extra  calls,  he  takes  a  stimu- 
lant. Yielding  to  this  temptation  is  often  the  first  step 
toward  ruin.  If  he  is  brainy  and  effective,  his  work  not 
only  continues,  but  grows,  and  he  is  frequently  con- 
fronted by  emergencies  which  call  for  the  expenditure  of 
more  strength  than  he  has,  and,  from  time  to  time,  he 
resorts  to  stimulants  of  one  kind  and  another  to  enable 
him  to  meet  them. 

Whisky  is  usually  taken  for  a  while,  but  that  soon 
begins  to  show  on  him,  and  its  telltale  odor  on  his  breath 
is  something  he  would  like  to  avoid.  In  seeking  some- 
thing to  take  its  place,  an  eighth  of  a  grain  of  morphine 
is  tried.  This  overcomes  the  sense  of  fatigue,  and  tides 
over  the  emergency  more  satisfactorily  than  whisky  did, 
and,  apparently,  does  not  have  as  bad  after-effects. 

His  work  increases  and  a  demand  for  longer  work- 
ing hours  continues  to  come,  and  he  finds  himself  resort- 


26  Narcotic  Drug  Diseases  and  Allied  Ailments. 

ing  to  the  stimulant  more  and  more  often.  Then  he 
begins  to  think  about  the  matter,  and  asks  himself  the 
question:  "Am  I  taking  any  risk  in  doing  this?  It  is 
true  that  I  would  not  advise  anyone  else  to  do  as  I  am 
doing;  but,  I  have  perfect  control  of  myself, — in  fact, 
I  know  myself,  and  I  can  take  it  or  not,  just  as  I  wish." 

He  tries  this,  and  the  fact  that  he  can,  at  this  stage, 
take  it  or  leave  it  alone  leads  him  to  feel  that  he  is  entire 
master  of  the  situation,  and  in  that  belief  he  goes  on 
taking  a  dose  occasionally,  and  at  other  times  refraining 
from  doing  so,  but  always  fully  confident  of  his  own 
power  of  self-control.  Thus,  his  overconfidence  in  him- 
self, coupled  with  a  lack  of  convictions,  leads  him  to 
resort  to  the  drug  to  lengthen  out  his  working  hours  and 
to  sustain  him  in  every  emergency,  either  real  or  imagi- 
nary, until,  before  he  is  aware  of  it,  he  has  reached  a 
stage  where  he  finds  himself  unable  to  do  his  work  with- 
out the  support  of  an  artificial  stimulant. 

At  this  stage  he  could  still  stop  the  use  of  the  drug  if 
he  would  quit  work,  but  he  feels  totally  unequal  to 
the  tasks  before  him  unless  he  has  the  support  of  a 
stimulant. 

He  realizes  that  he  should  go  away  for  a  rest,  but  if 
he  goes  away  his  clientele  will  fall  into  the  hands  of  his 
rival,  and  he  thinks  he  cannot  afford  to  allow  that,  or, 
possibly,  he  is  in  a  section  where  there  is  no  one  to  take 
his  place,  he  has  some  very  sick  patients  on  hand,  and  he 
feels  that  their  lives  would  be  jeopardized  by  his  leaving 
just  at  that  time,  or  his  obstetric  engagements  are  such 
that  he  could  not  get  away  without  leaving  them  pro- 
vided for. 

Reasoning  thus,  he  continues  to  work  under  stimula- 
tion and  to  put  off  to  a  "more  convenient  season"  taking 
the  rest  which  would  enable  him  to  stop  the  stimulant, 


Over  confidence  Leads  to  Addiction.  27 

until,  before  he  realizes  it,  he  has  passed  the  point  at 
which  he  could  stop  it  even  by  quitting  work ;  in  fact,  he 
has  inadvertently  woven  around  himself  chains  which  he 
is  in  no  wise  able  to  break.  He  is  a  helpless  victim  in 
the  hands  of  a  monster  with  whom  he  is  unable  to  cope. 

This  is,  in  substance,  the  history  of  probably  75  per 
cent,  of  professional  men  who  have  fallen  victims  to 
morphine.  These  victims  have  been  drawn  from  among 
our  most  talented  and  active  men,  and  this  has  occurred, 
as  a  rule,  during  the  first  ten  years  of  their  practice. 

Now,  the  motives  that  prompted  this  course  were  not 
vicious;  neither  did  real  elements  of  dissipation  enter 
into  it.  It  is  not  just  to  class  these  men  as  perverts  and 
to  stigmatize  them  as  fiends,  to  brush  them  aside  as  men 
who  are  willfully  abandoned  to  a  loathsome  habit,  which 
they  could  quit  if  they  would.  Their  numbers  are  too 
great,  and  they  come  from  too  respectable  a  source  to  be 
either  abandoned  or  condemned  without  justice  or 
reason. 

The  only  blameworthy  elements  that  entered  into 
their  enslavement  were,  first,  lack  of  fixed  convictions  as 
to  the  use  of  stimulants,  overconfidence  in  their  powers 
of  self-control,  with  probably  an  inordinate  ambition. 
These,  conspiring  together,  led  the  victim,  unawares,  to 
hopeless  slavery. 

The  number  of  persons  in  this  country  who  become 
addicted  to  narcotics  as  a  real  dissipation  is  compara- 
tively small.  The  indiscreet  use  of  the  drug  for  the 
relief  of  pain  is  the  chief  cause  of  the  addiction  (disease) 
among  the  laity,  and  its  use  by  physicians  to  enable  them 
to  work  longer  hours  accounts  for  it  in  a  majority  of 
instances  where  professional  men  are  involved. 


CHAPTER  II. 
SYMPTOMATOLOGY 

IN  order  to  convey  a  clear  idea  of  the  symptoms  of 
narcotic  drug  disease,  it  is  necessary  to  divide  and  class- 
ify them  with  reference  to  the  stages  of  the  disease.  It 
will  be  well  to  consider  them  under  the  headings  of 
symptoms  which  indicate  the  use  of  opiates  in  small 
quantities ;  also  in  large  quantities. 

Symptoms  which  indicate  the  deprivation  of  the  ac- 
customed drug. 

Symptoms  which  indicate  the  use  of  other  drugs 
with  the  opiate,  such  as  cocaine,  atropine,  scopolamine, 
etc. 

Symptoms  which  may  be  expected  to  develop  under 
the  different  forms  of  treatment  used  to  cure  the  disease, 
both  during  treatment  and  during  convalescence. 

SYMPTOMS  INDICATING  THE  USE  OF  OPIUM. 

The  easiest  and  most  commonly  noticed  symptom 
which  would  indicate  the  use  of  an  opiate  is  contraction 
of  the  pupil.  The  normal  pupil  accommodates  itself  to 
the  variations  of  light,  and  if  one  in  a  normal  condition 
is  placed  where  the  light  is  dim,  or  it  is  comparatively 
dark,  the  normal  pupil  dilates  in  order  to  admit  as  much 
light  as  possible.  But,  when  the  light  is  turned  on,  the 
pupil  contracts  at  once  so  as  to  exclude  an  excess  of 
light.  This  normal  activity  of  the  pupil  is  well  under- 
stood, but  in  drug  users  the  power  of  accommodation  is 
often  almost  entirely  suspended. 

Under  the  stimulating  effects  of  the  opiate  the  pupil 
is  contracted,  and,  even  if  light  be  excluded,  the  pupil 
(28) 


Normal  Accommodation  Suspended.  29 

does  not  dilate  to  any  considerable  extent,  and,  upon 
turning  the  light  on,  the  degree  of  change  in  the  size  of 
the  pupil  is  less  than  in  a  normal  person.  This  is 
regarded  as  one  of  the  most  certain  signs  of  the  use  of  a 
narcotic. 

The  condition  of  the  pupil,  however,  varies  much 
with  different  stages  of  narcotic  impression.  Soon  after 
taking  the  opium  the  pupil  is  minutely  contracted,  and 
remains  so  during  the  active  stimulating  period  of  this 
narcotic  impression.  But,  as  the  effect  of  the  drug  dies 
away,  the  pupil  dilates,  and  if  no  repetition  of  the  dose  is 
made  within,  say,  twenty-four  hours  the  pupil  will  be 
found  at  the  end  of  that  time  to  be  larger  than  normal. 
Under  the  stimulation  the  period  of  contraction  lasts  for 
a  time,  but,  upon  the  waning  of  stimulation,  the  pendu- 
lum swings  the  other  way,  and  the  pupil  is  abnormally 
large  for  a  time. 

Upon  the  cessation  of  the  use  of  the  opiate  the  pupil 
will  soon  regain  its  normal  accommodation.  But,  in 
drug  users,  these  doses  are  repeated  daily,  or  sometimes 
a  number  of  times  during  the  day,  and  the  pupil,  there- 
fore, is  kept  contracted  most  of  the  time,  and  this  gives 
the  eye  of  an  opium  user  a  dull,  lifeless  appearance. 

A  convenient  method  of  testing  the  reaction  of  the 
pupil  to  light  is  to  place  the  hand  tightly  over  the  eye 
and  hold  it  there  for  about  a  half-minute,  then  quickly 
remove  the  hand.  If  the  pupil  does  not  contract  when 
the  light  is  allowed  to  come  in  contact  with  the  eye,  it  is 
evident  that  the  eye  is  not  in  a  normal  condition. 

In  order  to  conceal  this  telltale  symptom — the  con- 
tracted pupil — drug  users  frequently  combine  some 
mydriatic  drug  with  the  opiate  they  are  taking,  usually 
a  little  cocaine,  or  atropine,  or  hyoscine.  These,  if  taken 
in  small  quantities  with  the  opiate,  have  a  tendency  to 


30  Narcotic  Drug  Diseases  and  Allied  Ailments. 

dilate  the  pupil,  thus  counteracting  to  a  great  degree  the 
effect  of  the  opiate  on  the  pupil ;  therefore,  in  such  cases 
one  may  be  deceived  as  to  the  condition  when  judging 
from  the  pupil  only. 

However,  even  in  these  cases,  although  the  pupil  may 
be  as  large  as  normal,  if  the  light  test  be  tried  upon  the 
patient,  it  will  be  found  that  the  pupillary  reaction  is 
distinctly  modified.  Under  the  blunting  effects  of  the 
narcotic  the  responsiveness  of  the  reflexes  is  reduced  and 
the  pupil  will  not  react  normally  to  light  when  the  patient 
is  under  the  influence  of  a  drug,  notwithstanding  that 
one  of  the  drugs  may  have  a  tendency  to  dilate,  and  the 
other  to  contract,  the  pupil. 

Another  very  characteristic  symptom  of  drug  users 
is  the  variability  of  their  mood.  Persons  who  take  the 
drug  are  usually  exhilarated  during  the  early  hours  of 
the  narcotic  impression,  but  this  is  followed  by  depres- 
sion of  spirits,  or  even  moroseness,  as  the  effect  of  the 
drug  passes  away.  Therefore  when  a  man  varies  in 
mood  from  hour  to  hour  it  is  a  strong  indication  that  he 
is  being  influenced  by  some  drug. 

This  variable  mood  will  often  manifest  itself  in  ex- 
cessive talkativeness,  during  the  period  of  the  early  or 
stimulating  effects  of  the  drug,  and  this  will  be  succeeded 
by  an  undue  reticence  or  quietude,  as  the  drug  dies  away. 
Such  a  person,  at  this  stage  of  the  narcotic  impression, 
may  be  seen  to  retire  from  the  company,  to  come  back 
in  half  an  hour  full  of  life  and  spirits.  These  variable 
moods  are,  almost  certainly,  due  to  the  effect  of  some 
drug. 

Drowsiness  or  a  tendency  to  sleep  is  also  one  of  the 
effects  of  the  drug,  but  this  does  not  come  on  at  the 
same  stage  of  narcotic  impression  in  all  individuals. 
That  is  to  say,  the  primary  effect  of  the  opiate  brings  on  a 


Narcotic  Habitues  Rarely  Ever  Sneeze,  31 

condition  of  sleepiness  in  some  persons,  while  others  are 
made  wide-awake  and  active  during  the  early  impression 
of  a  narcotic,  only  to  become  drowsy,  or  intensely  sleepy, 
as  the  effect  wears  away.  This  depends  upon  the 
personal  peculiarity  of  the  individual. 

Another  symptom,  usually  present,  which  indicates 
the  use  of  an  opiate  is  itching  of  the  nose.  This  is 
shown  by  an  almost  constant  desire  to  scratch  or  rub  the 
end  of  the  nose.  This  is  much  more  marked  in  the 
earlier  period  of  the  use  of  the  drug  than  later.  A 
symptom  which  appears  at  a  later  date  is  a  peculiar 
harshness  of  the  voice.  This  is  more  noticeable  at  some 
hours  of  the  day  than  at  others,  depending  upon  the 
stage  of  narcotic  impression. 

Another  symptom  which  is  of  diagnostic  value  is  the 
absence  of  sneezing.  Persons  who  use  an  opiate  habit- 
ually do  not  sneeze,  that  is,  they  do  not  sneeze  so  long 
as  they  take  the  opiate  regularly,  but  if  they  are  deprived 
of  the  drug  so  that  they  go  several  hours  beyond  the 
time  for  taking  their  dose  they  will  begin  to  sneeze  and 
the  sneezing  will  be  persistent  and  frequent  until  it  is 
arrested  by  the  effects  of  another  dose.  When  they  are 
uniformly  impressed  with  their  drug  it  is  almost  impos- 
sible to  make  them  sneeze  by  the  application  of  snuff  or 
other  irritant  to  the  Schneiderian  membrane. 

The  condition  of  the  skin  also  shows  evidences  of 
the  use  of  narcotics,  if  that  structure  be  carefully  ob- 
served at  different  stages  of  the  narcotic  impression  and 
at  different  hours  of  the  day.  The  effect  of  the  narcotic 
at  first  is  to  dry  the  skin,  but  as  the  primary  effects  wear 
away  there  is  a  disposition  to  sweat.  Therefore,  per- 
spiration occurring  at  intervals  and  at  times  and  under 
conditions  when  others  do  not  perspire  is  a  symptom 
which  strongly  indicates  the  use  of  a  narcotic. 


32  Narcotic  Drug  Diseases  and  Allied  Ailments. 

There  are  exceptions  to  this  rule,  but  they  are  com- 
paratively rare.  It  will  be  found  that  for  several  hours 
after  the  usual  dose  of  drug  has  been  taken  the  skin  is 
dry,  but,  as  the  drug  effect  wanes,  perspiration  begins 
and,  from  that  time  until  the  next  regular  period  for 
taking  the  drug,  the  skin  is  moist,  and,  if  the  patient  goes 
much  beyond  the  fixed  time  before  taking  his  dose,  per- 
spiration becomes  excessive.  Therefore,  this  variable 
activity  of  the  skin  is  an  indication  of  the  use  of 
narcotics. 

However,  all  these  symptoms  may  mislead  and  it  may 
at  times  become  the  duty  of  the  physician  to  determine 
with  certainty  whether  or  not  a  given  individual  is  really 
addicted  to  a  narcotic  drug.  By  applying  what  might 
be  called  the  crucial  test,  one  who  is  familiar  with  such 
matters  can  determine  with  certainty,  in  a  few  days' 
time,  whether  or  not  the  suspected  individual  is,  or  is  not, 
addicted  to  a  narcotic  drug. 

To  make  this  test,  the  following  steps  should  be 
taken:  Let  the  suspected  person  be  turned  over  to  a 
nurse  who  is  absolutely  reliable.  Let  the  patient  be 
taken  to  a  bathroom,  stripped,  and  given  a  bath,  and 
while  he  is  in  the  bathtub  let  the  nurse  take  the  clothing 
he  has  been  wearing,  including  hat,  shoes,  and  under- 
wear, and  remove  them  from  the  room  and  put  in  a 
locker.  When  the  bath  is  completed,  furnish  the  patient 
with  nightshirt  or  gown  and  then  take  him  to  a  room  in 
which  he  has  never  been  before  and  put  him  to  bed. 
If  patient  is  a  woman  her  hair  must  be  taken  down  and 
all  artificial  hair,  etc.,  removed. 

Let  a  watch  be  placed  over  him,  to  the  end  that  it  be 
made  impossible  for  him  to  secure  a  drug,  and  let  his 
conduct  be  observed.  If  he  is  not  addicted  to  a  narcotic 
drug  he  will  pass  the  time  in  comfort  just  as  any  other 


Symptoms  of  Enforced  Abstinence.  33 

normal  person  would  do.  If  he  is  addicted  to  a  drug, 
the  time  for  his  accustomed  dose  will  soon  approach. 
Up  to  that  time,  there  would  usually  be  no  evidence  of 
his  addiction.  But,  as  this  time  arrives,  he  will  begin 
to  show  signs  of  nervousness  or  restlessness. 

These  may  be  concealed  for  a  few  hours  beyond  the 
time  for  his  accustomed  dose;  but  when  that  time  has 
passed  and  the  physical  demand  for  the  drug  begins  to 
make  itself  felt,  if  he  is  addicted  to  an  opiate,  there  will 
certainly  be  reactionary  symptoms  which  cannot  be  con- 
cealed. The  skin  of  the  patient  will  become  unduly 
moist,  his  pulse  rate  will  be  greater  than  normal,  and,  in 
six  to  eight  hours  after  the  time  at  which  he  has  been 
accustomed  to  take  the  dose,  the  temperature  will  begin 
to  rise  and  will  continue  to  rise  until  there  is  a  distinct 
fever. 

The  patient  will  be  restless,  nervous,  and  despondent ; 
will  complain  of  pain  in  the  limbs  and  back,  with  more  or 
less  inclination  to  colicky  pain  in  the  bowels,  and,  if  the 
addiction  is  at  all  well  established,  nausea  will  soon 
make  its  appearance.  And,  before  this  test  has  been 
carried  much  further,  the  patient  will  most  likely  be  led 
to  confess  the  truth. 

But  if  he  stands  this  test  for  forty-eight  hours  with- 
out showing  reactionary  symptoms  it  is  positive  evi- 
dence that  he  is  not  addicted  to  a  narcotic  drug. 

No  matter  how  stoical  one  may  be,  he  cannot  conceal 
a  condition  such  as  this  and  keep  down  the  physical 
symptoms  that  arise  upon  the  abrupt  withdrawal  of  an 
opiate.  If  these  symptoms  do  not  make  their  appearance 
during  the  first  forty-eight  hours  of  this  test,  the  physi- 
cian may  be  satisfied  that  the  patient  is  not  a  drug 
addictee. 

The  evidences  of  the  use  of  narcotic  drug  when  the 
use  is  carried  to  extremes  are  very  marked.  The  symp- 


34  Narcotic  Drug  Diseases  and  Allied  Ailments. 

toms  occurring  in  those  who  use  drugs  in  moderate 
quantities  appear  in  an  exaggerated  degree  in  those  who 
use  larger  quantities.  The  indifference  and  want  of  care 
of  the  person  present  a  most  marked  contrast  between 
one  who  uses  large  and  one  who  uses  small  quantities 
of  narcotics. 

Very  few  persons,  indeed,  will  keep  their  persons 
clean  if  they  are  addicted  to  the  use  of  narcotics  in  any- 
thing like  large  quantities.  This  unkempt  condition  is 
so  marked  that  one  can  readily  pick  these  people  out 
upon  sight. 

Some  persons  do,  however,  succeed  in  using  opiates, 
even  in  large  quantities,  and  in  keeping  that  fact  from 
becoming  known.  They  have,  by  long  and  systemati- 
cally cultivated  habit,  learned  to  keep  themselves  in 
practically  a  uniform  condition  under  the  effects  of  the 
opiate.  This  is  looked  upon  as  their  normal  state,  and, 
as  they  are  never  seen  in  any  other  condition,  one  does 
not  suspect  the  use  of  an  opiate.  But  opium  users  who 
are  thus  consistent  and  methodical  in  their  life  are  ex- 
tremely rare.  Many  of  them  think  that  they  are  keeping 
their  addiction  concealed,  but  they  deceive  only  them- 
selves. 

SYMPTOMS  WHICH  INDICATE  THE  USE  OF  OTHER 
DRUGS  WITH  AN  OPIATE. 

The  combination  of  cocaine  with  morphine  is  a 
common  form  of  addiction  and  persons  who  take  such  a 
combination  of  drugs  manifest  distinctly  different  traits 
of  character  from  those  who  take  opiates  alone.  Cocaine 
to  some  extent  opposes  the  effects  of  morphine,  and, 
instead  of  there  being  such  periods  of  depression  and 
despondency  as  occur  in  those  who  use  morphine  alone, 
the  waking  hours  of  those  who  use  cocaine  with  their 


Behavior   of  Cocaine  Habitues.  35 

morphine  are  spent  in  the  condition  of  exaggerated 
stimulation. 

The  dose  of  the  drug  is  taken  very  much  more  often 
than  when  morphine  alone  is  used.  In  fact,  there  is 
a  constant  effort  to  balance  the  effects  of  the  two  drugs 
on  the  system.  If  a  little  more  impression  of  the  mor- 
phine is  developed  than  suits  the  particular  fancy  of  the 
addictee,  he  at  once  injects  a  little  cocaine  to  counter- 
balance this  unwholesome  effect,  and  probably  in  doing 
so  he  gets  a  little  more  impression  from  the  cocaine  than 
is  desired,  and  then  more  morphine  is  taken  to  over- 
come that. 

One  who  is  taking  drugs  in  this  combination  can 
hardly  do  anything  but  attend  to  his  own  physical  wants, 
injecting  a  little  cocaine  now  and  a  little  morphine  a 
short  time  afterward,  then  a  little  cocaine  to  counter- 
balance that.  Thus,  he  is  engaged  from  early  morning 
until  late  at  night  in  trying  to  keep  the  effects  of  these 
two  drugs  exactly  balanced  in  his  system. 

The  period  of  drowsiness  that  occurs  in  those  who 
use  opium  or  morphine  alone  does  not  occur,  but  when 
a  patient  has  dosed  himself  through  the  day  and  up  to 
a  late  hour  at  night,  and  decided  to  discontinue  his  dosing 
and  take  sleep,  he  soon  becomes  drowsy  and  falls  into 
a  heavy  slumber,  which  lasts  from  twelve  to  eighteen 
hours,  extending  probably  well  into  the  following  day. 
Then,  just  as  soon  as  he  is  awake,  before  he  is  able  to 
arise  from  the  bed  and  dress  himself,  a  dose,  and  often 
from  two  to  three  doses,  of  his  morphine-cocaine  solu- 
tion are  taken. 

The  behavior  of  the  cocaine  habitue  is  very  charac- 
teristic, especially  in  walking.  He  will  not  persist  in 
doing  any  one  thing  long.  If  he  starts  out  for  a  walk, 
he  will  travel  in  one  direction  probably  half  a  block, 


36  Narcotic  Drug  Diseases  and  Allied  Ailments. 

then  abruptly  turn  to  the  right  or  left  and  go  in  a 
straight  course  again  for  a  short  distance,  and  then  he 
will  "tack"  again  in  some  other  direction,  going  in  a 
zigzag  course,  instead  of  walking  straight  along  the 
street  or  road. 

This  zigzag,  or  "tacking,"  course  of  travel  is  very 
noticeable  in  one  who  is  under  the  influence  of  cocaine. 
Such  persons  usually  walk  rapidly,  as  if  in  a  great 
hurry.  They  are  nervous  and  fidgety  and  excessively 
talkative.  The  appetite  is  so  variable  that  they  will,  at 
times,  eat  enough  at  one  meal  for  four  or  five,  and  then 
not  take  a  mouthful  of  anything  to  eat  for  one,  two,  or 
three  days. 

A  person  addicted  to  a  combination  of  atropine  or 
hyoscine  with  morphine  presents  certain  peculiarities 
not  seen  in  any  other  form  of  addiction.  Those  who 
are  addicted  to  these  commonly  combined  drugs  have  a 
fidgety  disposition  that  is  very  characteristic. 

Almost  constantly,  during  their  waking  hours,  they 
are  in  motion,  never  being  entirely  still  as  much  as  one- 
tenth  of  a  minute,  unless  they  are  asleep.  This  constant 
disposition  to  move  is  noticeable  to  some  extent  in  the 
morphine-cocaine  addiction,  but  it  is  much  more  marked 
in  those  who  are  addicted  to  morphine  and  atropine. 

The  use  of  this  combination  of  drugs  is  usually  begun 
by  taking  tablets  containing  %  grain  of  morphine  and 
M.SO  grain  atropine.  As  the  morphine  is  increased  the 
atropine  is  increased  proportionately,  ]/2  grain  morphine 
carrying  with  it  Vrs  grain  atropine,  and  so  on,  until  by 
the  time  the  individual  is  taking  6  grains  of  morphine 
per  day  he  is  getting  with  it  24Aso  grain  of  atropine; 
this  quantity  of  atropine  renders  one  extremely  nervous 
and  fidgety.  Those  addicted  to  morphine-atropine  suffer 
greatly  from  insomnia. 


Symptoms  Developing   Under  Gradual   Withdrawal.       37 

Persons  thus  addicted  suffer  from  extreme  nausea 
if  morphine  is  taken  without  the  atropine,  so  that  they 
find  it  very  difficult  to  change  from  that  combination 
to  morphine  alone. 

SYMPTOMS  WHICH  INDICATE  DEPRIVATION  OF  THE 
ACCUSTOMED  DRUG  AND  THOSE  WHICH  MAY  BE 
EXPECTED  TO  DEVELOP  UNDER  GRADUAL  WITH- 
DRAWAL. 

The  author  does  not  approve  of  the  use  of  the 
gradual-reduction  method  in  treating  narcotic  addiction, 
yet  this  work  would  be  incomplete  without  a  description 
of  the  symptoms  and  conditions  which  develop  under  and 
following  such  a  course  of  treatment. 

That  the  author  may  not  be  charged  with  prejudice 
in  recording  the  conditions  which  arise  under  the  grad- 
ual withdrawal  of  opiates,  rje  thinks  it  best  to  allow 
others  to  record  these  conditions.  Dr.  J.  C.  Wilson,  in 
Pepper's  "System  of  Medicine,"  vol.  v,  pp.  657,  658, 
and  659,  says: — 

"Opium  habitues,  differing  as  they  do  among  themselves  in 
the  manifestation  of  the  drug  as  long  as  it  is  freely  taken,  all 
alike  develop  characteristic  symptoms  upon  its  speedy  or  gradual 
withdrawal. 

"The  nervous  system,  whether  it  has  been  accustomed  for 
months  only  or  for  years  to  the  influence  of  opiates,  is  upon  its 
withdrawal  forthwith  thrown  into  derangement  of  the  most 
serious  and  widespread  kind.  In  the  course  of  a  few  hours  after 
the  last  dose,  the  steadying  influence  of  the  drug  disappears. 
General  malaise  is  associated  with  progressive  restlessness.  The 
ability  to  perform  the  ordinary  duties  of  life  gives  way  to  pro- 
found indifference.  Precordial  distress  accompanied  by  cough 
is  followed  by  insomnia,  hallucinations,  and  sometimes  by  mania. 
The  habitual  pallor  of  the  face  is  replaced  by  a  deep  flush  or 


38  Narcotic  Drug  Diseases  and  Allied  Ailments. 

cyanosis.  The  heart's  action  becomes  excited  or  irregular,  then 
feeble;  the  pulse,  at  first  tense,  becomes  slow,  thready,  and 
irregular.  Colliquative  sweats  appear;  attacks  of  yawning  and 
sneezing  are  followed  by  convulsive  twitchings  of  the  hands; 
speech  becomes  hesitating,  drawling,  and  stuttering.  These 
phenomena  are  associated  with  a  sense  of  perfect  prostration 
which  obliges  the  patient  to  take  to  his  bed.  Pain  in  the  back 
and  limbs  followed  by  neuralgia  occurs.  Complete  anorexia  with 
easily  provoked  or  even  causeless  vomiting,  and  persistent  nausea 
and  diarrhea  difficult  to  control,  adds  to  the  gravity  of  the 
condition. 

"During  the  early  days  of  abstinence  the  evidences  of  cardiac 
failure  are  marked.  Enfeeblement  of  the  first  sound,  irregularity 
of  the  heart  action,  and  intermissions  are  common.  Restlessness 
is  continuous  and  very  often  intense  and  patients  are  with  diffi- 
culty kept  in  bed;  if  left  to  themselves  they  move  frantically 
about  the  room,  moaning,  bewailing  their  conditions,  and  begging 
the  attendants  for  that  which  alone  is  capable  of  relieving  their 
distress.  This  condition  gradually  subsides,  giving  way  to  one 
of  profound  exhaustion.  The  exhaustion,  due  to  reaction  of  the 
nervous  system,  deprived  of  the  stimulus  of  the  drug,  is  on  one 
hand  favored  by  pre-existing  derangements  of  the  nutritive  proc- 
ess, and  on  the  other  increased  by  the  pain,  wakefulness,  diar- 
rhea, and  vomiting  which  accompany  it.  The  appearance  of  the 
patient  is  now  most  pitiable;  his  countenance  is  blanched  and 
pinched,  the  body  occasionally  drenched  with  sweat,  the  heart 
acting  feebly,  and  the  pulse  irregular." 

Of  gradual  reduction,  Erlenmeyer  says: — 
"The  patient  after  withdrawal  is  left  in  such  a  condition  of 
physical  weakness  and  mental  dilapidation  as  to  be  the  victim  of 
intolerable  suffering  and  unfit  for  enjoyment  or  application  to 
work.  He  cannot  sleep,  he  has  no  appetite,  often  vomits,  feels 
too  much  used  up  to  rise  from  bed.  This  condition  continues  for 


Erroneous  Conception  of  Pathology. 


39 


a  long  time  and  grows  worse   from  week  to  week.     Various 
attempts  at  cure  prove  useless.     Morphine  is  the  only  remedy." 

It  would  seem  that  descriptions  such  as  the  above  by 
writers  of  unquestioned  authority  would  deter  anyone 
from  undertaking  the  treatment  of  an  opium  habitue  by 
gradual  reduction,  yet  this  method  has  the  almost  uni- 
versal endorsement  of  medical  writers.  Even  our  latest 
works,  such  as  Osier's  "Modern  Medicine,"  Ander's 
"Practice,"  and  other  authors  of  the  highest  standing, 
endorse  the  gradual-reduction  method  of  treatment  as 
the  accepted  mode  of  procedure. 

This  plan  of  treatment  seems  to  be  based  upon  the 
idea  that  the  narcotic  impressions,  that  is,  the  narcotic 
in  the  system,  constitutes  the  sum  total  of  the  malady. 

They  insist  that  the  drug  should  be  gradually  with- 
drawn, and  hold  out  the  impression  that  when  the  last 
of  the  drug  is  withdrawn  the  patient  will  be  cured;  in 
fact,  some  of  them  insist  that  we  can  hold  before  the 
patient  the  most  alluring  prospect  of  complete  freedom 
as  soon  as  the  last  of  the  drug  has  been  given  up.  They 
take  no  thought  of  or  seem  not  to  recognize  the  other 
pathological  conditions  present. 

It  is  true  that  the  narcotic  drug  is  a  toxic  substance 
and  its  presence  in  the  system  would  have  a  toxic  and 
deranging  effect,  but  the  drug  itself  is  present  in  so  much 
smaller  quantities  than  other  poisons  which  it  imprisons 
in  the  system  that  it  is  a  comparatively  minor  factor  in 
the  production  of  the  symptdns  which  develop  upon  the 
withdrawal  of  the  drug. 

The  withdrawal  of  the  drug  without  removing  these 
other  irritating  poisons  from  the  system  leaves  the 
patient  to  contend,  single-handed  and  alone,  with  this 
accumulated  toxic  matter,  and  he  is  utterly  unable  to  do 
so  with  success.  When  the  narcotic  impression  is  re- 


40  Narcotic  Drug  Diseases  and  Allied  Ailments. 

duced  to  any  considerable  extent  below  that  to  which 
the  patient  is  accustomed,  the  nervous  system  then 
begins  to  feel  the  irritating  effects  of  the  toxins  of  auto- 
and  intestinal  origin  with  which  the  system  is  saturated, 
and  in  response  to  this  irritation  the  various  manifesta- 
tions of  distress  develop. 

And,  even  if  success  is  attained  in  withdrawing  the 
last  particle  of  drug,  the  patient's  system  is  still  left  in 
an  unwholesome  condition.  So  long  as  any  narcotic 
impression  is  made  the  excreting  organs  are  retarded 
in  their  work  and  a  residue  of  toxic  matter  accumulates 
each  day.  When  the  last  of  the  drug  is  discontinued, 
the  patient  is  left  without  its  support  or  its  restraining 
effects  on  the  system,  and  the  real  battle  begins. 

Diarrhea  of  an  exhausting  character  sets  up  and  this 
often  continues  until  the  patient's  bowel  is  so  excoriated 
that  something  must  be  done  for  relief.  Various  reme- 
dies, astringents,  colonic  flushing,  etc.,  may  give  some 
relief,  but  they  do  not  quiet  the  nervous  system  or 
entirely  overcome  the  distress.  Under  these  conditions 
the  appetite  is  absent  and  the  patient,  instead  of  building 
up,  constantly  loses  weight.  He  becomes  discouraged,  if 
not  entirely  desperate. 

In  this  wretched  condition  he  will  seek  relief  at  any 
cost  and  will  use  any  kind  of  narcotic  or  anodyne 
which  will,  to  any  degree,  mitigate  his  suffering.  Under 
the  compulsion  of  such  distressing  conditions  patients  of 
this  character  will  conceal  drugs  and  bring  them  into  the 
institution,  or  do  anything  in  their  power  that  will 
bring  them  relief,  and  such  conduct  has  been  held  to  be, 
or  regarded,  as  a  lack  of  candor  and  good  faith  on  their 
part.  It  is  at  this  point  that  most  of  them  pass  from 
under  the  care  of  the  physician.  Or,  if  they  remain 
under  his  care  it  will  often  be  found  that  they  have 


Symptoms  of  Sudden  Suppression.  41 

secretly  secured  something  to  take  in  this  extreme 
emergency,  and  that  entirely  nullifies  the  efforts  of  the 
physician  to  free  them  from  their  addiction. 

Any  course  of  treatment  which  brings  a  human  being 
into  such  a  wretched  state,  and  involves  such  an  ordeal 
of  suffering  as  does  the  reduction  methods,  cannot  be 
too  strongly  condemned,  and  the  author  cannot  but 
express  surprise  that  writers  of  such  note  still  continue 
to  endorse  such  procedure. 

SYMPTOMS  WHICH  ARISE  UPON  THE  SUDDEN 
SUPPRESSION  OF  THE  OPIATE. 

Other  writers  who  consider  the  habitual  use  of 
narcotic  drugs  a  mere  vice  insist  upon  their  immediate 
withdrawal,  and  they  advise  this  without  any  regard  for 
its  consequences  to  the  patient.  The  abrupt  withdrawal 
of  an  opiate  from  persons  addicted  to  its  use  without 
first  preparing  the  patient's  system  for  such  withdrawal 
is  not  only  dangerous  to  life,  but  it  is  barbarous. 

This  course  is  not  now  pursued  in  any  reputable 
institution  for  the  treatment  of  drug  addiction,  but  it 
is  often  practised  in  our  insane  hospitals  and  jails. 
Persons  who  are  addicted  to  narcotic  drugs  are  arrested, 
thrown  into  a  cell,  without  any  provision  whatever  to 
supply  them  with  the  drug,  and  within  twenty-four  or 
forty-eight  hours  the  victim  is  taken  from  the  cell  a 
corpse,  having  sunk  into  a  complete  collapse. 

In  fact,  this  end  comes,  often,  within  twelve  hours 
after  the  arrest,  because,  in  many  instances,  the  poor 
wretch  has  been  unable  to  secure  his  drug,  and  it  was 
his  conduct  when  suffering  this  deprivation  that  led  to 
his  arrest.  He  was  already  in  extremis  when  arrested, 
and,  being  thrown  into  a  cell,  where  he  is  helpless  and 
unprotected,  he  soon  sinks  into  collapse  and  death  closes 


42  Narcotic  Drug  Diseases  and  Allied  Ailments. 

the  scene.  There  should  be  a  rigid  law  enacted  to  re- 
quire officials,  when  taking  in  charge  persons  of  this 
type,  to  see  that  they  are  attended  by  a  physician  and 
supplied  with  the  drugs  to  protect  them  from  these 
extreme  conditions. 

That  it  may  be  seen  that  the  views  of  the  author  are 
in  entire  accord  with  other  writers  upon  the  subject,  the 
following  quotations  are  given : — 

"This  method  of  the  abrupt  withdrawal  is  attended  in  all 
cases  by  indescribable  suffering,  and,  in  many,  by  serious  results. 
Among  the  last,  collapse  and  delirium  tremens  demand  special 
consideration.  The  collapse  which  occurs  in  a  certain  propor- 
tion of  cases  requires  thorough  and  energetic  treatment.  Failure 
of  the  circulation  may,  notwithstanding  every  effort  to  control  it, 
reach  such  a  degree  as  to  jeopardize  the  patient's  life."  (Pepper's 
"System  of  Medicine,"  vol.  v,  pp.  673,  675,  and  676.) 

Of  the  sudden  withdrawal,  Erlenmeyer  says : — 

"The  physician-in-chief,  or  his  subordinate,  must  be  with  the 
patient  night  and  day  for  the  first  few  days  of  treatment,  when 
the  struggle  will  be  greatest.  There  will  be  a  collapse  of  the 
vital  forces  and  it  may  be  a  matter  of  life  and  death  with  the 
patient,  and,  in  this  hour  of  danger,  ripe  experience,  presence  of 
mind,  and  readiness  in  emergencies  are  necessary  in  the  physician 
and  attendants. 

"They  must  pitilessly  resist  the  importunities  of  the  patient 
for  morphine,  while  at  the  same  time  they  must  not  lose  their 
compassion  and  sympathy  for  the  poor  sufferer.  There  will  be 
numerous  symptoms  constantly  occurring,  such  as  vomiting,  diar- 
rhea, and  restlessness,  etc.,  which  will  demand  the  attention  and 
keep  the  medical  attendant  and  nurse  busy ;  there  will,  for  a  time, 
in  fact,  be  no  rest  for  anybody. 

"The  responsibility  of  keeping  the  patient  from  inflicting 
injury  on  himself  is  no  light  strain  on  the  nerves  of  the  physician, 


Coercion  Damaging.  43 


who  must  exercise  untiring  vigilance,  and  no  one  can  endure  this 
strain  more  than  twelve  hours  without  respite  and  rest." 

(How  long  can  the  patient  be  expected  to  endure  this? 
[Author.] ) 

"The  sudden  withdrawal  entails  horrible  suffering  and  is 
utterly  inexcusable."  (Merrell's  "Therapeutics.")  "The  apart- 
ment occupied  by  the  patient  must  be  so  arranged  as  to 
guard  against  the  attempts  of  suicide."  (Pepper's  "System  of 
Medicine.") 

It  is  evident  that  the  cure  of  a  drug  addictee  could 
not  be  expected  from  so  barbarous  a  process.  It  is 
strange  that  anyone  could  lead  himself  to  believe  that 
subjecting  any  human  being  to  such  an  ordeal  of  suffer- 
ing as  is  involved  in  the  abrupt  withdrawal  of  opiates, 
without  preparatory  and  protecting  treatment,  could 
result  in  any  benefit  to  the  patient. 

Coercion  of  this  kind  has  done  much  to  prejudice  the 
cause  of  the  drug  users.  Under  such  extreme  conditions 
they  have  been  forced  to  do  things  to  protect  themselves 
which  have  been  interpreted  as  perversions  of  character, 
and  this  has  militated  against  their  receiving  that  degree 
of  consideration  to  which  their  condition  justly  entitles 
them. 

However,  if  the  proper  course  of  preparatory  treat- 
ment is  carried  out,  opiates  can  be  withdrawn  from 
those  addicted  to  their  use  without  danger  to  life  and 
with  much  less  suffering  than  is  usually  encountered  by 
the  methods  heretofore  in  vogue. 

As  has  been  pointed  out  in  the  chapter  on  Pathology, 
the  essential  pathology  of  this  condition  is  intoxication 
of  drug,  intestinal,  and  auto-  origin.  Most  of  the  symp- 
toms incident  to  the  withdrawal  of  drugs  are  due  to  these 
toxins.  In  fact,  all  of  the  dangerous  symptoms  are 
caused  by  them  and  most  of  the  painful  symptoms  are 
due  to  them  also. 


44  Narcotic  Drug  Diseases  and  Allied  Ailments. 

if  the  system  be  thoroughly  cleansed  from  toxic 
matter  of  internal  origin,  morphine  or  other  narcotic 
drugs  can  be  at  once  withdrawn  from  an  habitue  with- 
out danger  to  life  and  the  suffering  incident  to  such  a 
withdrawal  will  be  reduced  so  much  compared  to  what 
it  would  have  been  without  such  a  course  of  preparatory 
treatment  that  the  condition  of  the  patient  will  not  bear 
any  resemblance  whatever  to  the  condition  of  one  who 
has  not  had  this  cleansing  treatment  preceding  the 
withdrawal. 

The  engorged  condition  of  the  portal  system  is  the 
chief  factor  in  bringing  about  a  labored  and  deficient 
heart  action,  and  this  deficient  heart  action  is  an  essen- 
tial factor  upon  which  collapse,  the  principal  dangerous 
symptom,  depends.  If  this  engorged  condition  is 
remedied,  then  the  other  conditions  developing  out  of  it 
do  not  occur  and  the  patient  can  weather  the  remainder 
of  the  storm  without  great  danger.  However,  he  would 
suffer  intensely,  but  that  suffering  would  have  a  natural 
limit  of  about  three  days.  After  that  time,  the  secondary 
effects  of  the  opiate  having  subsided,  the  reactionary 
symptoms  disappear  and  the  patient  reaches  a  condition 
of  fair  comfort. 

At  least  six  of  the  most  troublesome  and  dangerous 
complicating  symptoms  incident  to  the  abrupt  with- 
drawal of  opiates  have  their  origin  in  a  perverted  func- 
tion, viz. :  deficient  excretion.  These  are  intestinal  colic, 
nausea,  vomiting,  diarrhea,  labored  and  deficient  heart 
action,  and  collapse. 

By  thorough  elimination  these  may  be  prevented 
altogether  and  a  number  of  the  other  symptoms  of 
nervous  and  mental  origin  greatly  modified,  if  not  en- 
tirely obviated. 

But  many  of  the  nervous  and  mental  symptoms  inci- 
dent to  such  withdrawal  will  develop  and  continue  for 


Hypercsthesia  After  Withdrawal. 


45 


from  two  to  three  days.  The  patient  would  suffer 
intensely  during  that  time  and  this  suffering  would 
seriously  impair  his  nervous  system,  weaken  him  physi- 
cally, and  lessen  his  powers  of  resistance,  but  the  danger 
to  life,  so  prominent  from  the  withdrawal  without  elimi- 
nation, would  be  avoided. 

This  suffering,  severe  as  it  would  be,  can  be  obviated 
by  a  rational  course  of  treatment  and  these  distressing 
days  can  be  passed  in  comfort;  the  method  of  doing 
this  will  be  sufficiently  considered  under  the  head  of 
Treatment. 

As  another  chapter  in  this  book  will  be  devoted  to  the 
consideration  of  the  gradual  reduction  method  of  treat- 
ment, the  symptoms  developing  during  such  treatment, 
and  the  condition  of  the  patient  during  the  period  of 
convalescence,  together  with  the  effects  of  such  treat- 
ment on  the  mind  of  the  patient,  and  upon  his  future 
usefulness,  it  is  not  thought  necessary  to  consider  that 
method  of  treatment  farther  at  this  place. 

As  to  the  symptoms  during  convalescence  which 
follow  the  sudden  withdrawal  as  ordinarily  practised, 
if  the  patient  survives  so  that  any  symptoms  at  all  may 
develop,  suffice  it  to  say  the  patient's  system  is  left  in  an 
extremely  toxic  and  disordered  condition,  and  any  of  the 
physical  ailments  which  arise  from  toxic  conditions  may 
be  expected  to  develop  during  the  period  of  convales- 
cence. But  even  with  the  most  perfectly  balanced  and 
carefully  directed  course  of  treatment,  certain  symptoms 
arise  during  the  period  of  convalescence  which  seem  to 
be  unavoidable. 

Among  the  first  of  these  to  appear  is  a  general  hyper- 
esthesia.  The  nervous  system  of  the  patient  being  long 
accustomed  to  work  under  the  restraint  of  this  anesthe- 
tizing drug,  when  this  restraint  is  withdrawn,  wakes  up 


46  Narcotic  Drug  Diseases  and  Allied  Ailments. 

to  such  a  degree  of  activity  that  a  general  hyperesthesia 
is  present. 

In  other  words,  the  condition  of  anesthesia  which 
exists  and  becomes  a  chronic  state  under  the  influence 
of  the  continued  use  of  opiates  is  succeeded  by  a  hyperes- 
thesia equally  marked  and  which  continues  for  a  con- 
siderable length  of  time  after  the  complete  withdrawal 
of  the  drug. 

This  hyperesthesia  not  only  manifests  itself  in  undue 
sensitiveness  of  the  sensory  nerves,  but  also  in  many 
other  parts  of  the  nervous  system.  Even  in  the  con- 
versation of  the  patients  there  is  an  element  of  excit- 
ability, and  the  slightest  opposition  or  mental  stimulation 
brings  on  a  mental  excitement  that  is  altogether  ab- 
normal. 

It  is  evident  that  the  brain  and  spinal  centers,  being 
released  from  the  restraining  effects  of  the  opiate,  are 
too  sensitive  and  respond  abnormally  to  any  stimulation, 
either  physical  or  psychic,  and  this  condition  of  hyper- 
sensitiveness  or  hyperesthesia  continues  in  some  cases 
for  several  months.  In  others  a  few  weeks  serve  to 
terminate  it. 

Another  symptom  which  is  unavoidable  is  a  slight 
rise  of  temperature,  especially  during  the  afternoon  of 
each  day.  The  author  has  taken  much  pains  to  deter- 
mine the  cause  of  that  symptom,  but  is  uncertain  yet  as 
to  which  of  three  or  four  factors  is  most  potent  in  its 
causation.  This  fever  appears  in  practically  every  case 
and  continues  sometimes  as  long  as  four  weeks  after  the 
entire  withdrawal  of  the  drug. 

In  the  opinion  of  the  author  any  one  of  several 
conditions  that  are  evidently  present  might  account  for 
the  fever.  We  have  just  seen  that  the  condition  of  the 
nervous  system  is  one  of  general  hyperesthesia.  In  this 


Fever  Following   Withdrawal,   Source   of.  47 

condition  it  is  likely  that  the  heat-centers  are  so  dis- 
turbed that  there  is  a  loss  of  balance  between  the  rate  of 
heat  production  and  heat  radiation,  thus  allowing  an 
expression  of  hyperpyrexia. 

Then,  again,  the  nervous  system,  in  fact  the  whole 
organism,  has  become  accustomed  to  doing  its  work 
under  the  restraint  of  the  opiate.  This  restraint  being 
withdrawn,  it  is  likely  that  all  the  vital  functions  would 
be  carried  on  at  a  more  active  rate  than  normal,  the 
nerve-centers  being  hypersensitive.  This  would  doubt- 
less lead  to  the  greater  than  normal  production  of  heat. 

Again,  the  system  is  usually  anemic  and  there  is  a 
great  demand  for  nourishment.  This  being  taken,  there 
is  increased  activity  of  the  digestive  process.  The  in- 
creased oxidation  incident  to  this  increased  metabolism 
involves  increased  heat  production.  If  the  nerve-centers 
are  disturbed  so  that  the  radiation  of  heat  is  imperfectly 
adjusted  to  heat  production,  it  is  evident  that  there 
would  be  hyperpyrexia  from  more  active  metabolism. 

But  more  likely  than  either  of  these  is  that  there 
remains  a  residue  of  toxic  matter  in  the  system — in  the 
ultimate  cell — which  the  most  persistent  and  thorough 
elimination  cannot  remove  at  once,  and  that  the  fever 
is  due  to  the  effects  of  this  remnant  of  toxic  matter  upon 
the  hypersensitive  nervous  system. 

While  the  bowel  may  have  been  thoroughly  emptied 
and  the  kidneys  and  skin  made  to  do  their  full  duty, 
or  even  more,  it  would  be  practically  impossible  to  per- 
fectly cleanse  the  system  of  such  an  accumulation  of 
toxic  matter  in  a  few  days,  or  even  a  week  or  more  time. 
Therefore,  it  is  probable  that  there  would  remain  stored 
away  in  the  tissues  in  the  very  structure  of  the  cells  a 
residue  of  toxic  matter,  and  that  this  would  act  as  an 
exciting  cause  of  the  fever. 


48  Narcotic  Drug  Diseases  and  Allied  Ailments. 

The  nerve-centers,  being  hypersensitive,  would 
respond  with  undue  activity  to  this  toxic  matter. 

Then,  again,  with  this  hypersensitive  state  of  the 
nerve-centers  the  slightest  absorption  of  toxin  from  the 
intestines  would  result  in  an  acute  intestinal  toxemia 
which  would  be  attended  by  some  fever,  and  this  doubt- 
less is  its  source  in  some  cases. 

But,  whatever  may  be  the  correct  explanation  of  its 
cause,  it  is  present  and  when  left  uncontrolled  greatly 
increases  the  discomfort  of  the  patient  during  conva- 
lescence. 

The  more  perfectly  the  system  has  been  cleansed  of 
toxic  matter f  the  less  fever  will  follow  the  withdrawal 
of  the  drug  and  the  less  pain  there  will  be  during  the 
period  of  convalescence.  Therefore,  the  author  is  in- 
clined to  be  satisfied  with  the  idea  that  this  fever  is  of 
toxic  origin. 

The  height  of  the  temperature  is  usually  about  %° 
in  the  morning,  running  to  %°,  %°,  or  probably  to  i%° 
in  the  late  afternoon.  This  gradually  subsides,  disap- 
pearing in  some  cases  as  early  as  the  second  week,  while 
in  others  it  continues  to  the  fourth  or  fifth  week.  The 
duration  is  influenced  to  a  considerable  extent  by  the 
dietary  habits  of  the  patient. 

In  the  afternoon,  when  the  temperature  rise  amounts 
to  as  much  as  %°  or  %°,  there  is  more  or  less  dis- 
comfort, aching  of  the  limbs,  etc.  Antipyretics  do  not 
make  much  impression  on  this  temperature,  that  is,  the 
coal-tar  derivatives  do  not.  Aspirin,  on  the  other  hand, 
does  reduce  the  temperature  and  give  relief  from  the 
painful  symptoms  arising  from  it.  Another  useful  agent 
is  pilocarpine.  This  brings  about  a  moist  state  of  the 
skin  accompanied  by  remission  of  fever  and  gives  much 
relief  through  a  general  relaxation  of  the  entire  system. 


Effect  of  Overtaxing  Digestive  Organs.  49 

The  appetite  after  the  withdrawal  of  opiates  is 
usually  ravenous  and  if  the  patient  be  left  to  follow  his 
own  inclinations  he  will  eat  more  than  he  is  able  to 
digest,  and  this  will  often  be  followed  by  digestive  dis- 
turbances of  the  most  marked  character.  It  could  not  be 
expected  that  such  disturbances  would  not  develop. 

The  stomach  is  no  stronger  than  any  other  part  of 
the  patient's  body,  yet  it  is  called  upon  to  do  a  full  day's 
work  each  day.  If  the  patient  were  called  upon  on  these 
days  to  do  a  day's  work  of  any  kind,  he  would  be  totally 
unequal  to  it.  Therefore,  it  would  be  unreasonable  to 
expect  the  stomach  to  do  full  work  in  such  a  debilitated 
condition. 

If  the  patient  is  left  to  gratify  his  appetite  at  will,  in 
from  one  to  two  weeks  he  will  overtax  the  digestive 
organs  to  such  a  degree  that  acute  digestive  disturbances 
will  develop,  and  these  are  attended  by  much  discomfort. 
Unless  the  patient  is  warned  against  this  and  made  to 
understand  the  cause  of  his  suffering,  as  well  as  the 
means  of  relieving  it,  this  distress  will  cause  his  mind 
to  revert  to  the  opiate  and  probably  lead  him  to  take 
something  of  that  kind  for  relief  of  this  acute  ailment. 

This  is  one  of  the  reasons  why  a  patient  should, 
remain  in  an  institution  and  under  the  supervision  of  his 
physician  for  a  considerable  time  after  being  taken  off 
of  the  drug.  He  must  be  taught  to  live  free  from  excess 
of  every  kind,  but  especially  should  excesses  in  eating 
and  drinking  be  avoided,  since  it  is  only  by  this  course 
that  relapse,  can  be  avoided. 

With  the  error  as  to  diet  in  general  that  is  prevalent 
throughout  the  world,  the  physician  will  be  called  upon 
to  teach  his  patients  many  things  along  these  lines  and 
to  supplant  error  with  real  physiological  truths.  This 
is  no  small  undertaking,  but  it  is  just  as  essential  to  sue- 


50  Narcotic  Drug  Diseases  and  Allied  Ailments. 

cess  in  an  effort  to  restore  the  drug  slave  to  complete 
self-mastery  as  the  therapeutic  measures  were  in  the 
early  treatment  of  the  case. 

Drug  patients  eat  very  heartily  and  they  often  take 
on  weight  at  a  very  rapid  rate.  This  increase  of  weight 
is  largely  due  to  the  accumulation  of  fat  rather  than 
muscle,  and  this,  at  times,  becomes  an  encumbrance  to 
them.  This  new  tissue  should  be  developed  into  stout 
muscular  fiber  by  a  proper  course  of  physical  training 
and  outdoor  exercise. 


CHAPTER  III. 

TREATMENT. 

THE  treatment  of  narcotic  drug  addiction  from  the 
earliest  mention  of  this  condition  in  medical  literature 
seems  to  have  been  undertaken  under  the  assumption,  or 
belief,  that  the  habitual  use  of  narcotics  was  a  mere  vice, 
an  indulgence,  and  that  all  that  was  involved  in  the  treat- 
ment was  to  secure  the  renunciation  of  that  vice,  the 
discontinuance  of  the  use  of  the  drug. 

As  it  was  found  extremely  difficult  to  secure  the 
breaking  away  from  the  habit  at  once,  it  was  thought 
that,  since  it  had  had  a  progressive  and  slow  growth, 
the  natural  and  most  successful  way  to  bring  it  to  an 
end  was  to  gradually  reduce  the  quantity  of  the  drug 
taken  until  it  was  entirely  discontinued. 

Many  ingenious  schemes  for  carrying  out  this 
gradual  reduction  method  of  treatment  were  devised. 
This  method  of  treatment  has  had,  and  still  has,  the 
endorsement  of  leading  medical  writers;  but  it  is  as 
unreasonable  and  unscientific  as  it  is  unsuccessful. 

It  is  based  on  a  total  misconception  of  the  nature  of 
the  condition  to  be  treated,  and,  just  as  reasoning  from 
false  premises  leads  to  false  conclusions,  so  the  treating 
of  a  disease  with  a  false  idea  of  its  pathology  gives 
faulty  results.  In  this  instance  the  results  have  been 
even  worse  than  faulty.  It  is  not  believed  that  as  many 
as  two  persons  out  of  each  hundred  treated  by  gradual 
reduction  have  been  cured. 

The  writer  would  not  condemn  this  method  so 
strongly  if  failure  to  cure  was  all  the  effect  it  had  had 
on  the  ninety-eight  out  of  each  hundred  who  submitted 

(51) 


52  Narcotic  Drug  Diseases  and  Allied  Ailments. 

to  it  without  being  cured.  But,  mere  failure  to  secure 
a  cure  was  not  all ;  the  impressions  made  on  their  minds, 
the  lasting  damage  to  their  mentality,  were  such  as  to 
reduce,  very  greatly,  their  chances  of  being  finally  cured. 

In  the  chapter  upon  Reasons  for  Past  Failures  in  the 
Treatment  of  Morphinism,  the  author  will  give  his  views 
at  greater  length  upon  the  gradual  reduction  method  of 
treatment. 

Eleven  years  ago  the  author  published  his  first  paper 
on  "Narcotic  Drug  Addiction."  In  that  paper  twenty- 
one  propositions  as  to  the  pathology  and  treatment  of 
narcotic  addictions  were  advanced,  none  of  which  had, 
prior  to  that  time,  appeared  in  medical  literature.  As 
these  propositions  have  stood  the  test  of  time  and  an 
extensive  clinical  experience  since  that  time  has  only 
led  to  their  enlargement  and  amplification,  it  is,  he  trusts, 
with  a  pardonable  pride  that  they  are  here  restated, 
notwithstanding  such  restatement  involves  a  practical 
reproduction  of  matter  used  elsewhere.  They  are,  in 
substance,  as  follows : — 

1.  The  essential  pathology  of  narcotic  drug  addiction 
is  a  toxemia,  the  toxins  being  of  drug,  auto-,  and  intes- 
tinal origin. 

2.  At  least  six  of  the  most  troublesome  and  danger- 
ous complicating  symptoms  have  their  origin  in  a  per- 
verted function,  viz.:   deficient  excretion.     These  are 
intestinal  colic,  nausea,  vomiting,  labored  and  deficient 
heart  action,  and  collapse.     By  thorough  elimination 
these  may  be  prevented  altogether,  and  a  number  of  the 
other  symptoms  of  nervous  and  mental  origin  greatly 
modified,  if  not  avoided. 

3.  The  motor  function  of  the  bowel  is  the  function 
most  impaired  by  the  effects  of  opiates. 

4.  Purgatives,    secretory   stimulants,   as   ordinarily 
given,  which  excite  intestinal  motion  by  reflex  action, 


Stimulation  of  Motor  Function  Essential.  53 

do  not  sufficiently  restore  that  function  to  bring  about 
effective  emptying  of  the  intestinal  canal  of  a  drug  user. 

5.  In  order  to  empty  the  intestinal  canal  of  a  drug 
user  direct,  positive  stimulation  of  the  motor  centers  is 
essential,  strychnine  being  the  most  suitable  agent  for 
this  purpose. 

6.  Since  in  narcotic  drug  users  all  the  nerve-centers 
are  profoundly  impressed  with  the  narcotic,  resulting 
in  extreme  lethargy  of  intestinal  motion,  larger  than 
ordinary   medicinal   doses   of   strychnine   are   required 
to   overcome   this   lethargic   state  and   excite   efficient 
peristalsis. 

7.  If  the  motor  activity  of  the  bowel  be  efficiently 
induced  and  maintained  by  direct  stimulation  of  the 
motor  centers  with  strychnine,  no  larger  quantity  of  the 
glandular  stimulants  is  required  to  promptly  and  fully 
empty  the  intestines  of  the  drug  user  than  in  those  not 
using  the  drug. 

8.  If   free   peristaltic   action   is   excited   while   the 
system  is  still  under  the  sedative  influence  of  morphine, 
little,  if  any,  distress  occurs  and  the  intestinal  canal  can 
be  thoroughly  and  promptly  emptied. 

9.  Strychnine,  if  given  in  sufficient  doses,  will  excite 
active  peristalsis,  notwithstanding  the  restraining  effects 
of  the  opium. 

10.  Unless  efficient  provisions  for  the  prompt  and 
full  excitation  of  the  motor  function  of  the  bowel  be 
made,  any  secretory  stimulant  given  will  merely  excite 
excessive  secretion  in  the  upper  part  of  the  intestinal 
canal,  accompanied  by  griping,  nausea,  vomiting,  and 
other  distress,  but  will  be  unable  to  empty  the  canal, 
reflex  action  alone  not  being  sufficient  to  induce  peri- 
stalsis when   the  nerve-centers   are   so  benumbed  by 
narcotics. 


54  Narcotic  Drug  Diseases  and  Allied  Ailments. 

11.  Deficient  heart  action  leading  to  collapse  in  these 
cases  is  mainly  due  to  portal  engorgement. 

12.  When  the  intestinal  canal  has  been  thoroughly 
cleansed  and  portal  engorgement  overcome,  morphine 
or  other  narcotics  can  be  at  once  withdrawn  from  an 
habitue  without  danger  to  life  and  without  the  occur- 
rence of  shock,  diarrhea,  colic,  vomiting,  or  the  slightest 
appearance  of  collapse. 

13.  A  general  hyperesthesia  follows  the  withdrawal 
of  opiates  from  an  habitue,  this  being  the  natural  re- 
action from  the  state  of  chronic  anesthesia  to  which  the 
drug  user  has  been  accustomed.    This  extends  to  all  of 
the  functions  of  the  body,  mental  as  well  as  physical. 

14.  The  severe  suffering  incident  to  the  abrupt  with- 
drawal of  opiates,  after  thorough  elimination  has  been 
carried  out,  has  a  natural  limit  of  a  few  days'  time.    This 
suffering,    severe   as    it   would   otherwise   be,    can   be 
obviated  and  these  days  passed  in  comfort  by  the  discreet 
administration  of  scopolamine. 

15.  The  therapeutic  use  of  scopolamine,  for  the  time 
it  is  required  in  these  cases,  does  not,  in  any  way,  per- 
petuate the  desire  or  necessity  for  the  use  of  an  opiate. 
While  it  relieves  pain,  induces  sleep,  and  overcomes  those 
distressing  symptoms  of  nervous  origin  that  follow  the 
withdrawal  of  morphine,  its  action  so  opposes  the  effects 
of  the  opiate  that,  instead  of  perpetuating  the  effects  of 
the  morphine,  it  stimulates  the  centers  which  have  been 
benumbed  by  that  drug  and  shortens  the  time  during 
which  its  secondary  effects  would  be  manifested. 

1 6.  When  the  patient's  system  has  been  thoroughly 
cleansed  from  toxic  matter,  the  drug  withdrawn,  and 
the  patient  prevented  from  suffering  with  scopolamine 
for  from  two  to  three  days,  no  craving  or  desire  for  the 
drug  remains,  abstinence  symptoms,  such  as  ordinarily 


Scopolamine,  Dose  and  Use  of.  55 

follow  the  withdrawal  of  opiates,  are  obviated,  and  the 
patient  is  brought  to  a  condition  in  which  he  can  pass 
his  time  in  comfort,  eat  heartily,  sleep  from  four  to  six 
hours  out  of  each  twenty-four,  and  this  insures  safe  and 
rapid  convalescence. 

17.  The  dose  of  scopolamine  cannot  be  definitely 
fixed.    The  dose  varies  greatly  in  different  individuals, 
the  range  being  from  1/300  to  */50  grain  at  intervals  of 
from  thirty  minutes  to  six  hours.     At  first  the  smaller 
doses  should  be  given  and  repeated  at  short  intervals 
until  sleep  is  induced,  or  at  least  until  the  patient  is  free 
from  all  pain.     After  this  the  dose  should  be  of  such 
size  and  be  given  at  such  intervals  as  are  necessary  to 
overcome  all  painful  symptoms  and  to  keep  the  patient 
comfortable.    The  dose  in  one  case  is  no  index  to  what 
will  be  required  in  the  next ;  only  by  a  physician  experi- 
enced in  such  matters  being  present  and  observing  the 
effects  of  each  dose  can  the  proper  dose  be  ascertained 
and  the  patient  be  kept  in  a  comfortable  condition. 

1 8.  The  patient  should  not  be  allowed  to   suffer. 
Scopolamine,    in   remedial   doses,   does   not   materially 
affect  the  vital  functions  or  leave  after-effects  on  either 
the  mind  or  body  of  the  patient ;  therefore,  it  should  be 
given  until  its  full  physiological  effects  are  manifested,  if 
necessary.     To  allow  the  patient  to  suffer  during  the 
treatment  impairs  his  nervous  system,  lengthens  the  time 
during  which  treatment  will  be  necessary,  and  materially 
increases  the  danger  of  the  relapse. 

19.  The  period  of  convalescence  during  which  the 
patient  must  be  kept  under  supervision  is  also  consider- 
ably reduced,  but  varies  greatly  in  different  individuals. 
The  absence  of  that  train  of  nervous  symptoms,  the 
ability  to  sleep  naturally,  to  eat  heartily,  and  the  im- 
proved digestion  and  assimilation  by  which  the  patient 


56  Narcotic  Drug  Diseases  and  Allied  Ailments. 

rapidly  gains  in  flesh  and  strength  lessen  the  liability  to 
relapse  almost  as  greatly  as  this  curative  plan  of  treat- 
ment lessens  the  dangers  and  sufferings  while  under 
treatment. 

20.  The  after-treatment  in  these  cases  does  not  con- 
sist in  the  administration  of  drugs,  and  no  drugs  should 
be  given  unless  specifically  indicated.    There  is  certainly 
no  place  for  the  administration  of  alcohol  or  strychnine 
in  the  after-treatment. 

The  reduction  or  suspension  of  inhibitory  control  by 
the  effects  of  alcohol  permits  an  extravagant  and  prema- 
ture expenditure  of  energy,  and  this  is  followed  by 
marked  depression.  This  depression  is  felt  to  an  exag- 
gerated degree  by  one  who  has  recently  been  taken  off 
of  a  narcotic  drug  and  such  a  one  will  not  long  tolerate 
it,  but  will  seek  to  blunt  their  sensibilities  to  it  by  taking 
more  alcohol.  This,  in  turn,  lessens  inhibitory  control, 
and  energy  is  again  prematurely  expended,  and  this  is 
followed  by  increased  depression. 

Depression  from  the  secondary  effects  of  alcohol  calls 
loudly  for  a  dose  of  the  narcotic  to  which  such  person 
had  been  accustomed  and  if  that  is  taken  the  person  is 
well  on  the  road  to  relapse.  Alcohol  in  all  forms  should 
be  interdicted  during  convalescence  and  forever  after- 
ward. 

Strychnine  keeps  up  too  active  peristalsis  and  in- 
clines the  bowel  to  empty  itself  too  often.  This  inter- 
feres with  digestion  and  assimilation  and  causes  diarrhea 
by  the  passage  of  incompletely  digested  food  through 
the  bowels. 

21.  Unloading    the   intestinal    canal    and    relieving 
portal  congestion  lessen  the  strain  under  which  the  heart 
has  been  working  more  than  enough  to  compensate  for 
the  loss  of  the  stimulus  it  derived  from  the  effects  of 


No   Antidote   or   Antitoxin   Available.  57 

morphine,  and,  instead  of  the  heart's  action  being  weak 
or  irregular,  the  character  of  the  pulse  is  decidedly 
improved.  It  has  greater  volume,  is  softer,  more  com- 
pressible, and  is,  in  every  respect,  of  better  quality  than 
when  propelling  the  blood  against  the  obstruction  of  an 
engorged  portal  system,  even  though  it  was  supported 
by  morphine.  However,  should  the  heart  action  be  weak, 
or  for  any  reason  need  support,  sparteine  sulphate,  I  to 
2  grains  hypodermically,  every  four  to  six  hours  will 
give  it  more  uniform  and  efficient  support  than  morphine 
or  any  other  known  drug. 

In  endeavoring  to  formulate  a  line  of  treatment  based 
upon  the  views  of  pathology,  etc.,  hereinbefore  men- 
tioned, the  mind  would  naturally  turn  to  the  thought: 
"Is  there  not  an  antidote,  an  antitoxin,  that  will  neu- 
tralize this  toxic  matter  in  the  system?"  Since  we  have 
a  toxemia  to  treat,  to  destroy  or  neutralize  those  toxins 
with  an  antibody  would  be  the  most  prompt,  and,  doubt- 
less, the  most  successful,  treatment.  But  when  the 
complex  character  of  the  toxemia  is  considered  we  could 
not  hope  to  secure  an  antitoxin  capable  of  destroying 
these  toxins  in  the  system. 

The  toxin  resulting  from  the  faulty  action  of  the 
liver  and  kidney,  from  the  intestinal  glands,  in  fact, 
from  each  organ,  would  necessarily  differ.  An  anti- 
toxin suitable  to  neutralize  the  poisons  arising  from 
faulty  action  of  one  of  these  organs  would  not  likely 
neutralize  those  made  from  another  organ.  Therefore, 
instead  of  endeavoring  to  neutralize  or  antidote  the 
toxins  in  the  system,  rational  medicine  demands  that  the 
excretory  functions  be  unlocked,  and  that  this  accumu- 
lated toxic  matter  be  removed  from  the  system. 

But  rational  medicine  also  demands  that  this  be  done 
in  the  most  conservative  manner  possible.  Narcotic 


58  Narcotic  Drug  Diseases  and  Allied  Ailments. 

drug  users  are  anemic  and  should  not  be  depleted 
unduly;  therefore,  purgatives  given  to  them  should  be 
compounded  so  as  to  act  in  the  most  conservative 
manner. 

By  uniform  and  proportionate  stimulation  of  all  of 
the  functions  concerned  in  the  evacuation  of  waste,  the 
system  can  be  thoroughly  cleansed  of  toxic  matter  with- 
out exhausting  the  patient's  strength  or  otherwise  taxing 
his  vital  energy. 

Let  us  consider  the  steps  necessary  and  the  agents 
most  suitable  to  be  used  in  this  undertaking.  First,  a 
tub  bath  followed  by  a  vapor  bath  will  aid  materially  in 
throwing  off  the  poisons.  This  should  be  regulated  ac- 
cording to  the  patient's  strength.  Free  drinking  of 
water,  to  flush  the  kidneys  and  carry  off  a  larger  per 
cent,  of  urea,  etc.,  will  aid  materially. 

But  these  are  each  of  minor  importance.  When  we 
consider  that  the  bile  and  bowel  discharges  are  nine  times 
as  toxic  as  the  urine,  and  that  the  urine  is  fifty  times  as 
toxic  as  the  perspiration  (Bouchard),  we  can  see  that 
even  a  small  discharge  from  the  bowel  contains  many 
times  more  toxic  matter  than  could  be  thrown  off  by  the 
skin  during  a  vapor  bath.  Therefore,  it  is  to  the  bowel 
we  must  look  for  the  discharge  of  most  of  this  poisonous 
matter. 

Since  we  have  seen  that  the  motor  function  of  the 
bowel  is  almost  completely  suspended  by  the  effects  of 
the  opiates,  it  is  evident  that  in  preparing  a  purgative 
course  we  should  arrange  to  overcome  the  semiparalyzed 
condition  of  this  essential  function. 

Any  purgative  compound  which  does  not  conform  to 
this  standard  will  only  distress  the  patient,  instead  of 
bringing  material  relief. 

The  author  has  found  the  following  formula  to  be  a 
physiologically  balanced  purgative  compound  and  one 


Thorough   Elimination   Most  Essential  Step.  59 

that  has  given  excellent  results  in  narcotic  cases  in  his 
hands : — 

1^  Calomel, 

Powdered  extract  of  cascara  aa  gr.  x. 

Ipecac    gr.  j. 

Strychnine   nitrate    gr.  %. 

Atropine  sulphate   gr.  Y50. 

M.  and  make  4  capsules.  Sig. :  One  every  two  hours  until 
4  are  taken,  preferably  at  4,  6,  8,  and  10  P.M.,  and  only  after 
having  abstained  from  dinner  and  supper  on  the  day  on 
which  they  are  taken. 

Thorough  elimination  of  toxic  matter  from  the 
system  is  the  primary  and  most  essential  step  in  the 
treatment  of  morphinism. 

The  principal  obstacle  in  securing  action  of  purga- 
tives in  drug  addictees  arises  from  the  suspension  of 
peristalsis  by  the  primary  effects  of  the  opiates.  During 
a  period  varying  from  four  to  eight  hours  from  the  time 
of  taking  the  dose  of  morphine  intestinal  motion  is 
almost,  if  not  entirely,  absent;  but  as  the  early  effects 
of  the  dose  subsides,  peristalsis  is  again  gradually  re- 
established. 

Drug  users,  as  a  rule,  take  their  drug  only  during 
the  day,  or  from  the  time  of  rising  in  the  morning  until 
bedtime — say,  from  8  A.M.  until  10  P.M.  During  these 
hours  the  system  is  kept  constantly  under  the  primary 
effects  of  the  opiate,  and  intestinal  motion  is  very  much 
restricted,  but  between  10  P.M.  and  8  A.M.  the  effects 
of  the  day's  dosing  wear  away  and  peristalsis  becomes 
fairly  active,  and  it  is  during  the  latter  part  of  this  period 
that  the  excretory  organs  do  the  principal  part  of  their 
work.  In  order  to  secure  efficient  action  of  purgatives 
advantage  must  be  taken  of  this  state  of  affairs. 


60  Narcotic  Drug  Diseases  and  Allied  Ailments. 

The  remedies  must  also  be  so  compounded,  and  be 
given  at  such  times,  as  to  have  the  acme  of  their  effects, 
both  as  motor  and  secretory  stimulants,  occur  during  the 
latter  part  of  this  period,  when  the  system  is  least  under 
the  restraining  influence  of  the  opiate. 

To  do  this,  begin  with  the  capsules  made  by  the 
formula  above  given,  at,  say,  4  P.M.,  and  let  the  last  dose 
be  given  about  10  P.M.  Let  the  patient  be  given  the 
opiate  in  his  usual  doses  up  to  8  or  10  P.M.,  but  none 
must  be  given  from  that  time  until  after  the  bowel  has 
been  thoroughly  emptied  on  the  following  morning. 

Nothing  in  the  way  of  nourishment  should  be  allowed 
to  go  into  the  patient's  stomach  during  a  period  begin- 
ning as  much  as  six  hours  before  the  time  of  giving 
the  first  purgative  capsule  and  ending  after  the  purga- 
tion is  completed.  Then  the  patient  may  be  given 
nourishment. 

If  the  patient  is  of  average  size  and  weight  and  no 
opiate  is  given  after  the  time  of  giving  the  last  purgative 
capsule,  the  strychnine  and  atropine  in  these  capsules 
will  excite  a  fair  degree  of  peristalsis,  notwithstanding 
the  restraining  effects  of  the  opiates,  and  this  will  enable 
the  glandular  stimulants  given  with  them  to  induce  free 
evacuation  from  the  bowel  in  from  eight  to  ten  hours 
after  the  time  of  giving  the  last  purgative  capsule,  thus 
securing  bowel  movement  before  the  time  for  the  usual 
morning  dose  of  morphine. 

But  more  certainly  to  secure  this  result,  six  or  eight 
hours  from  the  time  of  giving  the  last  purgative  capsule 
give  l/2o  grain  of  strychnine,  hypodermically,  and  follow 
this  half  an  hour  later  by  2  ounces  of  castor  oil  or  a  bottle 
of  citrate  of  magnesia.  Both  the  strychnine  and  the  oil 
or  saline  should  be  repeated  at  intervals  of  two  hours 
until  the  intestinal  canal  has  been  thoroughly  emptied. 


Details  of  Treatment.  61 

It  is  essential  that  no  morphine  or  other  narcotic 
be  given  during  this  time. 

If  the  bowel  begins  to  act  before  the  time  for  taking 
the  usual  morning  dose  of  morphine  the  patient  will  ex- 
perience little,  if  any,  discomfort;  but  on  the  contrary, 
the  relief  afforded  by  the  active  elimination  will  be  such 
as  to  enable  the  individual  to  go  for  several  hours  beyond 
the  time  for  the  morning  dose  of  narcotic  without  feeling 
the  need  of  it,  and  this  should  be  done,  thus  allowing  as 
much  time  for  elimination  as  possible. 

When  the  patient  has  gone  as  long  as  he  can  without 
discomfort  and  begins  to  feel  the  need  of  the  drug  he  has 
been  taking,  it  should  be  given  him,  but  in  reduced  doses. 
It  will  be  found  that  after  the  bowel  has  been  thoroughly 
emptied  and  the  patient  has  gone  without  his  drug 
several  hours  beyond  the  usual  time  of  taking  it  not 
more  than  half  or  two-thirds  the  usual  dose  will  be  re- 
quired to  meet  the  demands  of  the  system. 

This  reduced  quantity  should  be  given  at  the  same 
intervals  at  which  the  individual  had  been  taking  doses 
of  morphine  before  beginning  the  treatment.  After  the 
purgation  has  been  complete  the  patient  may  be  allowed 
a  liberal  diet  until  within  six  or  eight  hours  of  the  time 
of  giving  the  next  course  of  purgative. 

Forty-eight  hours  from  the  time  of  the  first  purgative 
course  another,  consisting  of  the  same  ingredients, 
should  be  begun  and  given  as  the  first.  This  course  may 
be  less  or  more  active  than  the  first,  according  to  the 
effects  obtained  from  the  first,  but  no  one  of  the  several 
ingredients  should  be  left  out.  Each  of  these  does  an 
important  part  of  the  work  which  the  other  cannot  do  so 
perfectly  without  its  aid. 

After  the  first  purgative  course  has  acted  freely  the 
patient  should  be  given  his  morphine  in  as  small  doses 


62  Narcotic  Drug  Diseases  and  Allied  Ailments. 

as  will  keep  him  comfortable,  up  to  the  time  of  his 
evening  or  bedtime  dose  on  this,  the  second,  day  for 
giving  the  purgative  courses ;  but  no  morphine  or  other 
opiates  should  be  given  after  the  time  of  taking  the  last 
purgative  capsule  of  the  second  course. 

Six  or  eight  hours  from  the  time  of  giving  the  last 
purgative  capsule  of  the  second  course,  strychnine  and 
oil  or  saline  should  be  given  as  before  and  repeated,  if 
necessary,  until  free  bowel  movement  has  been  obtained. 
During  this  time  the  patient  should  be  given  a  bath  and 
put  to  bed. 

The  action  of  this  course  of  purgative  will  carry  into 
and  out  of  the  intestinal  canal  a  residue  of  extremely 
toxic  matter,  and  the  patient  will  experience  such  relief 
from  it  as  to  enable  him  to  go  even  longer  beyond  the 
time  for  his  accustomed  dose  than  he  did  after  the  first 
course,  especially  if  he  remains  in  bed,  which  he  should 
do. 

In  the  course  of  from  six  to  eight  hours  after  the 
time  for  his  morning  dose,  however,  he  will  begin  to  feel 
uncomfortable  and  require  something  for  relief;  then 
instead  of  giving  the  opiate  as  before,  scopolamine  in 
^2oo-grain  dose  should  be  given,  hypodermically,  and  the 
same  dose  repeated  in  thirty  minutes. 

An  average  patient  will  usually  fall  asleep  in  half  an 
hour  from  the  time  of  giving  the  second  dose  of  scopo- 
lamine ;  but  if  not,  and  if  he  is  at  all  uncomfortable,  the 
third  dose  of  the  same  size  may  be  given.  If  the  patient 
is  not  uncomfortable,  let  him  go  until  the  lapse  of  an 
hour  from  the  time  of  giving  the  second  dose.  If  at  the 
end  of  that  time  he  has  not  fallen  asleep  a  third  dose 
should  be  given. 

This  dose  may  be  of  the  same  size  as  the  other  two, 
or  it  may  be  increased  to  double  that  size,  depending  upon 


Details  of  Treatment.  63 

the  degree  of  impression  made  by  the  preceding  doses. 
If  the  patient  has  no  unusual  tolerance  for  the  drug, 
these  doses  will  bring  him  under  the  influence  of  the 
remedy  to  such  a  degree  as  to  either  induce  sleep  or  to 
establish  a  mild  belladonna  intoxication,  in  either  of 
which  conditions  he  is  free  from  suffering. 

If  he  does  go  to  sleep  he  should  be  allowed  to  sleep 
until  he  awakens,  even  if  that  be  six  or  eight  hours ;  but 
when  he  does  wake,  no  matter  how  comfortable  he  may 
be,  an  additional  dose  of  scopolamine  should  be  given. 
Usually  ^200  grain  is  sufficient,  but  that  must  be  regu- 
lated by  the  susceptibility  of  the  patient.  These  doses 
must  be  repeated  at  such  intervals  as  may  be  required 
to  keep  up  a  mild  belladonna  intoxication  and  to  keep 
the  patient  free  from  pain. 

He  may  sleep  more,  or  he  may  not,  but  that  does  not 
matter  so  long  as  he  is  kept  in  a  comfortable  condition. 
He  should  be  impressed  to  this  degree  with  the  scopo- 
lamine for  a  period  of  thirty-six  to  forty-eight  hours 
from  the  time  of  beginning  this  remedy,  and  then  all  the 
narcotic  medication  should  be  discontinued. 

During  the  time  the  patient  is  kept  under  the  influ- 
ence of  scopolamine  it  is  usually  well  to  give  20  grains 
of  sodium  hyposulphite  every  two  hours,  which  should 
be  continued  for  twenty-four  or  more  hours  after  the 
scopolamine  period  has  passed.  The  small,  frequently 
repeated  doses  of  hyposulphite  supplement  the  effect  of 
the  calomel  purge,  and  after  they  have  been  kept  up  for 
twenty-four  to  thirty-six  hours  the  patient  will  begin  to 
have  small,  bilious  stools  unattended  by  colic,  griping, 
or  other  distress  which  will  more  fully  cleanse  the  system 
of  toxic  matter  and  prepare  the  patient  for  a  rapid  and 
successful  convalescence. 

This  period  is  reached  by  the  end  of  the  fifth  or  sixth 
day  from  the  beginning  of  treatment,  after  which  no 


64  Narcotic  Drug  Diseases  and  Allied  Ailments. 

medication  is  indicated  so  far  as  the  addiction  itself  is 
concerned.  If  elimination  has  been  thoroughly  carried 
out,  the  patient  will  have  no  desire  for  his  drug,  nor  will 
he  suffer  because  of  abstinence. 

It  is  true  he  will  feel  weak  and  miss  the  support  of 
the  artificial  stimulant  to  which  he  has  been  accustomed, 
but  the  unbearable  nervousness,  hot  flashes,  aching  of 
the  limbs,  labored  heart  action,  sweating,  diarrhea,  rest- 
lessness, and  insomnia  so  prominent  under  most  other 
plans  of  treatment  will  be  absent  and  the  patient  will  be 
able  to  lie  quietly  in  bed  and  pass  his  time  in  comfort 
and  not  only  enjoy  taking  nourishment,  but  the  average 
patient  will  digest  and  assimilate  a  liberal  quantity  of  it. 

If  the  heart  action  is  at  all  deficient,  either  during  or 
after  treatment,  sparteine  sulphate  in  doses  of  2  grains 
at  intervals  of  four  to  six  hours  should  be  given,  as 
indicated;  but  it  is  rarely  necessary  to  use  anything  for 
this  purpose.  The  relief  afforded  the  heart  by  cleansing 
the  system  of  toxic  matter  and  unloading  the  portal 
system  is  more  than  enough  to  compensate  for  any  sup- 
port it  had  been  receiving  from  the  opiate,  and  the  cir- 
culation is  usually  better  than  it  was  under  the  opiate. 

The  period  of  convalescence  of  from  one  to  two 
months  should  be  spent  under  the  direct  supervision  of 
his  medical  adviser  and  preferably  in  an  institution  de- 
voted entirely  to  the  treatment  of  this  class  of  patients. 

It  is  a  mistake  to  undertake  the  treatment  of  such 
patients  at  their  homes  or  in  a  general  hospital.  Such 
environment  does  not  afford  the  physician  that  degree  of 
personal  supervision  of  the  case  and  control  of  the  sur- 
roundings necessary  for  the  welfare  and  protection  of 
the  patient.  Neither  does  it  afford  the  accessories  which 
may  be  used  to  advantage. 

In  a  properly  equipped  institution,  hydropathy,  elec- 
tricity, massage,  and  other  such  rational  means  are  at 


Routine  Treatment  Not  Effective.  65 

hand  and  can  be  employed  to  meet  any  slight  complica- 
tion from  which  the  patient  may  suffer,  and  thereby 
avoid  the  administration  of  medicine,  and  more  perfectly 
wean  him  from  dependence  on  drugs. 

The  active  therapeutic  measures  required  in  the 
treatment  of  these  cases  are  completed  in  a  few  days' 
time,  but  the  patient  must  not  be  considered  cured  simply 
because  he  has  been  taken  off  the  drug  and  brought  to 
a  condition  in  which  he  no  longer  wants  or  requires  it. 

Discreet  supervision  during  the  period  of  convales- 
cence is  as  essential  to  the  permanency  of  cure  as  the 
therapeutic  measures  were  to  its  beginning.  The  patient 
must  be  given  every  aid  possible  in  the  effort  to  regain 
his  self-control,  and  must  not  be  thrown  on  his  own 
resources  until  he  has  fully  reached  that  point.  From 
two  to  six  months  can  be  well  spent  in  securing  that 
result  by  anyone  who  is  seeking  freedom  from  drug 
slavery. 

No  two  cases  of  morphinism  are  exactly  alike  and  no 
routine  treatment  can  be  devised  to  meet  the  require- 
ments in  every  case.  However,  only  two  of  the  remedies 
thus  far  considered  will,  ordinarily,  need  to  be  varied  in 
quantity  or  time  of  administration.  These  are  the 
strychnine  and  scopolamine. 

The  more  opiate  that  is  being  used,  the  more  strych- 
nine will  be  required  to  overcome  its  paralyzing  effect  on 
the  motor  function  of  the  bowel.  The  age,  weight,  and 
physique  of  the  patient  must  also  be  considered  in  deter- 
mining the  quantity  of  strychnine  required.  The  differ- 
ence in  the  susceptibility  of  the  different  persons  to 
strychnine  can  be  estimated  with  a  fair  degree  of  accu- 
racy. The  tall,  loosely  built  person  with  flabby,  anemic 
tissues  requires  much  more  strychnine  to  bring  his 
muscular  system  to  a  fair  degree  of  tone  than  does  the 


66  Narcotic  Drug  Diseases  and  Allied  Ailments. 

small,  compactly  built,  whose  tissues  are  not  to  such  a 
degree  atonic. 

Unless  strychnine  be  given  in  these  cases  in  larger- 
than-ordinary  medicinal  doses,  satisfactory  results  can- 
not be  expected.  It  must  be  remembered  that  the  entire 
nervous  system  is  profoundly  blunted  with  the  sedative 
impression  of  the  opiate.  This  renders  the  nerve-centers 
very  unresponsive,  and  at  the  same  time  renders  the 
peripheral  nerves,  on  which  impressions  of  a  reflex 
nature  depend,  extremely  insensitive  to  any  peripheral 
irritation. 

In  this  condition,  if  we  are  to  establish  a  fair  degree 
of  motility  of  the  intestinal  canal,  we  must  administer 
strychnine  in  such  quantities  as  not  only  to  overcome  the 
paralyzing  effects  of  the  narcotic  on  the  nerve-centers, 
but,  in  addition,  sufficient  to  stimulate  efficient  motion. 
From  two  to  three  times  as  much  strychnine  is  required 
to  do  this  in  a  patient  under  a  narcotic  as  one  who  is 
in  a  normal  state. 

This  effect  can  be  produced  in  the  system  without 
the  slightest  approach  of  danger ;  in  fact,  until  the  motor 
centers  are  thoroughly  aroused  to  activity  there  is  not 
the  slightest  danger  of  an  overeffect  of  strychnine.  One 
grain  of  strychnine  is  the  smallest  dose  which  is  known 
to  have  produced  a  death  in  an  adult,  and  this  was  in  a 
normal  adult,  and  not  one  under  the  influence  of  an 
opiate.  Had  this  patient,  or  any  patient,  of  that  charac- 
ter been  profoundly  narcotized,  doubtless  this  dose  could 
have  been  taken  with  impunity.  However,  it  is  not 
necessary  to  push  strychnine  to  such  a  degree  as  to 
be  at  all  dangerous,  or  to  cause  the  patient  the  least 
discomfort. 

The  primary  effects  of  strychnine  are  exerted  on  the 
centers  which  govern  involuntary  motion.  Therefore, 


Tolerance  of  Strychnine  by  Drug  Habitues.  67 

muscular  fibers  of  the  unstriated  type,  such  as  are  found 
in  the  walls  of  the  intestines,  may  be  thoroughly  stimu- 
lated to  active  motility  before  the  centers  governing 
voluntary  motion  are  materially  affected.  In  other 
words,  strychnine  expends  its  force,  first,  through  the 
sympathetic  system  upon  the  functions  of  organic  life. 
Therefore,  these  can  be  excited  to  full  activity  before 
the  muscles  of  a  voluntary  type  are  affected  so  as  to 
develop  spasmodic  action,  upon  which  danger  from 
strychnine  depends. 

In  studying  this  question,  in  an  effort  to  arrive  at  the 
extent  to  which  strychnine  should  be  given  in  order  to 
secure  the  best  results,  the  author,  in  many  instances, 
gave  %  grain  of  strychnine  every  two  hours  until  four 
such  doses  were  given.  These,  of  course,  were  persons 
who  were  profoundly  under  the  influence  of  a  narcotic 
drug,  but  these  doses,  even  as  excessive  as  they  may 
seem,  did  not  produce  unpleasant  symptoms  or  cause 
perceptible  contraction  of  a  single  voluntary  muscle  or 
tendon. 

In  one  case,  a  male  patient  weighing  about  180 
pounds  who  had  lost  40  pounds  in  weight  and  was  about 
six  feet  tall,  and  whose  muscular  tissues  were  flabby  and 
relaxed,  %  grain  of  strychnine  was  given  every  two 
hours  until  four  such  doses  were  given,  making  I  grain 
of  strychnine  given  in  the  eight  hours.  Not  the  slightest 
discomfort  was  produced  by  these  doses.  This  patient 
was  taking  20  grains  of  morphine  per  day  hypodermi- 
cally,  and,  in  order  to  excite  anything  like  a  fair  degree 
of  intestinal  motion,  this  quantity  of  strychnine  was 
required. 

These  doses  of  strychnine  were  given  combined  with 
the  purgative,  calomel,  cascara,  etc.,  as  above  outlined. 
This  purgative  having  not  acted  in  eight  hours  from  the 


68  Narcotic  Drug  Diseases  and  Allied  Ailments. 


time  the  last  potion  of  it  was  given,  %  0  grain  of  strych- 
nine was  given  hypodermically,  followed,  in  half  an 
hour,  by  3  ounces  of  castor  oil.  An  hour  and  a  half  after 
this  the  patient's  bowel  began  to  act  and  he  had  free 
evacuations;  in  fact,  enormous  evacuations,  but  these 
were  unattended  by  any  distress  whatever. 

The  patient  was  not  nauseated  in  the  slightest  degree  ; 
there  was  no  colic  or  other  distress  ;  in  fact,  every  func- 
tion concerned  in  the  evacuation  of  waste  had,  by  this 
physiologically  balanced  purgative  course,  been  stimu- 
lated to  a  degree  sufficient  to  act  in  harmony  and  there 
was  no  more  distress  from  such  action  than  if  the  bowel 
had  been  acting  normally. 

Narcotic  drug  users  are,  ordinarily,  very  unpleas- 
antly affected  by  purgatives.  As  a  rule,  physicians  in 
preparing  a  purgative  compound  give  secretory  stimu- 
lants and  depend  upon  these  to  excite  the  other  func- 
tion essential  to  bowel  movements,  that  of  intestinal 
motion.  While  they  do  this,  they  do  it  so  indirectly  and 
so  imperfectly  that  before  the  entire  bowel  is  thrown  into 
motion,  so  as  to  make  evacuation  at  all  possible,  the 
secretion  induced  by  those  agents  has  overfilled  the  upper 
segments  of  the  intestinal  canal. 

This  overdistention  of  the  upper  segments  of  the 
intestine  causes  griping,  nausea,  vomiting,  and  other 
distress.  Direct  stimulation  of  the  motor  centers  with 
strychnine  induces  active  peristalsis  throughout  the 
entire  length  of  the  intestinal  tube  and  this  free  motility 
prevents  undue  accumulation  in  the  upper  part  of  the 
intestinal  canal  ;  in  fact,  as  the  secretions  induced  by  the 
secretory  stimulants  are  poured  out,  this  efficient  intes- 
tinal motion  carries  these  secretions  downward  gradu- 
ally, but  as  rapidly  as  they  are  formed,  thus  preventing 
the  overfilling  of  the  intestine  at  any  point. 


Strychnine,  Free  Use  of,  Necessary.  69 

The  overfilling  being  avoided,  there  is  nothing  to 
cause  the  disagreeable  symptoms  which  are  so  common 
when  a  secretory  stimulant  alone  is  given. 

During  the  early  years  of  the  author's  work,  in  the 
treatment  of  drug  addiction,  he  endeavored,  by  advice 
through  the  mails,  to  assist  in  the  treatment  of  many 
cases  of  drug  addiction.  This  was  undertaken  in  such 
cases  as  a  member  of  a  physician's  family,  or  of  some 
invalid  who  could  not  be  sent  to  an  institution  for 
treatment. 

It  was  his  earnest  desire  to  help  all  such  persons  and 
to  give  as  efficient  aid  in  the  matter  as  possible.  He  has 
written  hundreds  of  letters  of  instructions  to  physicians, 
each  based  upon  some  particular  case.  He  has  found  no 
difficulty,  as  a  rule,  in  having  any  part  of  his  instructions 
carried  out,  except  in  the  administration  of  a  sufficient 
quantity  of  strychnine  to  be  effective  in  these  cases. 

The  fact  that  strychnine  is  a  toxic  drug,  and  that  the 
dose  has  heretofore  been  so  much  underestimated,  has 
made  almost  all  physicians  hesitate  to  give  the  quantity 
required  in  these  cases.  He  found  the  physician  would 
give  the  prescription  for  the  purgative  in  every  detail 
as  written,  except  that  he  would  cut  down  the  quantity 
of  strychnine. 

This  reduced  quantity  being  insufficient  to  establish 
active  peristalsis,  the  action  of  the  purgative  was  disap- 
pointing. More  or  less  vomiting  and  other  distress 
preceded  or  attended  the  action  of  the  purgative,  and 
before  free  evacuation  of  the  bowel  could  be  obtained  the 
storm  of  distress  was  so  great  that  the  physician  was 
forced  to  give  an  opiate  to  allay  it. 

When  this  was  given  all  hope  of  further  action  from 
that  purgative  course  was  gone.  Thus,  the  most  essen- 
tial step  in  the  treatment,  the  thorough  elimination  of 


70  Narcotic  Drug  Diseases  and  Allied  Ailments. 

waste,  having  failed,  when  an  attempt  was  made  to  carry 
out  other  steps  in  the  treatment  the  condition  was  so 
complicated  by  the  toxic  matter  remaining  in  the  system 
that  satisfactory  results  could  not  be  obtained. 

Failure  to  give  strychnine  in  sufficient  quantities  to 
efficiently  provide  for  the  intestinal  motion  having  de- 
feated the  primary  and  most  essential  step  in  the  treat- 
ment, that  of  securing  free  evacuation  of  the  waste  from 
the  bowel,  all  the  symptoms  attendant  upon  the  with- 
drawal of  the  drug  were  aggravated.  The  remainder  of 
the  treatment,  if  carried  out  at  all,  was  done  with  the 
greatest  difficulty  and  the  results  were  unsatisfactory. 

Finding  such  extreme  difficulty  in  getting  this  essen- 
tial part  of  the  treatment  faithfully  carried  out,  he  has 
for  several  years  declined  to  assist  in  the  treatment  of 
any  cases  not  under  his  personal  supervision.  He  found 
that  he  was  doing  more  harm  than  good  and  was  bring- 
ing a  good  treatment  into  disrepute,  when,  had  his 
specific  directions  been  followed,  the  results  would  have 
been  otherwise. 

In  order  to  make  this  matter  more  clear,  if  possible, 
he  might  compare  the  motor  centers  to  a  man  asleep  in  a 
burning  building.  If  a  man  was  profoundly  asleep,  and 
the  building  was  burning,  one  who  was  seeking  to  arouse 
him  would  hardly  go  to  the  door  and  tap  gently,  and 
expect  to  arouse  him  from  profound  sleep  by  the  gentle 
and  lady-like  use  of  force — no ;  he  would  not  tap  gently, 
but  vigorously;  he  would  knock,  and  yell,  and  use  the 
most  vigorous  means  to  arouse  him  from  his  slumber  and 
bring  him  to  consciousness,  that  his  life  might  be  saved. 

Now,  in  narcotic  cases  the  entire  nervous  system,  the 
nerve-centers  which  preside  over  motion  and  secretion, 
is  as  profoundly  lethargic  as  was  this  sleeping  man. 
Does  it  not  seem  out  of  all  reason  to  administer  to  such 


Intestinal  Motion  Deficient.  71 

a  patient  only  the  quantity  of  motor  stimulants  that 
would  be  required  if  the  centers  were  in  normal  condi- 
tion? There  would  be  just  as  much  reason  to  depend 
upon  the  lady-like  tapping  on  the  sleeping  man's  door  to 
arouse  him  from  his  slumbers  as  there  would  be  to  expect 
the  ordinary  medicinal  doses  of  strychnine  to  arouse 
these  semiparalyzed  centers  to  activity  and  excite  an 
efficient  peristalsis. 

Unless  a  physician  has  the  courage  and  the  thera- 
peutic skill  to  administer  remedies  in  these  cases  in  suffi- 
cient quantities  to  procure  their  full  physiological  effects, 
he  ought  not  to  attempt  to  treat  patients  of  this  class. 
We  must  meet  conditions  as  we  find  them. 

In  severe  attacks  of  hepatic  or  renal  colic,  if  we  seek 
to  relieve  the  patient  with  morphine,  more  than  an  ordi- 
nary medicinal  dose  is  required.  One-fourth  grain  of 
morphine  is  a  fairly  effective  dose  in  most  conditions  in 
which  that  remedy  is  indicated,  but  in  severe  attacks  of 
hepatic  or  renal  colic  the  experienced  physician  would 
not  depend  upon  a  dose  of  that  size.  He  would  more 
likely  give  %  grain  as  an  initial  dose,  wait  fifteen  to 
thirty  minutes,  and  if  the  pain  was  not  arrested  he  would 
give  y±  grain  more,  and  this  would  probably  have  to  be 
repeated  once  or  twice  before  complete  arrest  of  pain 
ensued.  , 

In  such  conditions  it  often  requires  three  or  four 
times  the  ordinary  dose  of  a  narcotic  to  so  blunt  the 
sensory  centers  as  to  make  the  terminal  nerve  branches 
tolerate  the  presence  of  an  imprisoned  gall-stone  without 
sending  up  painful  sensory  impressions.  Conversely, 
when  we  seek  to  arouse  to  activity  motor  centers  which 
are  profoundly  blunted  by  the  effects  of  narcotics,  we 
must  give  a  sufficient  quantity  of  the  appropriate  remedy 
to  bring  about  that  result. 


72  Narcotic  Drug  Diseases  and  Allied  Ailments. 

This  is  not  rashness,  but  is  simply  rational  thera- 
peutics. Medicines  are  given  for  their  effects,  and  the 
quantity  required  to  produce  a  given  effect  is  governed 
by  the  condition  of  the  patient,  as  well  as  by  the  other 
physiological  conditions  known  to  affect  the  action  of 
remedies.  But  as  the  physiological  laws  governing  the 
action  of  purgatives  will  be  considered  more  at  length  in 
a  separate  chapter  in  this  volume,  nothing  more  will  be 
added  on  that  point  at  this  time. 

Very  erroneous  ideas  have  existed,  and  still  exist,  as 
to  the  office  and  value  of  hyoscine  (scopolamine)  in  these 
cases,  and  the  most  extravagant  claims  have  been  made 
for  it.  Many  of  these  claims  are  based  upon  a  total  mis- 
conception of  the  principles  underlying  the  successful 
treatment  of  narcotic  addiction. 

In  the  author's  original  paper  no  claim  was  made  for 
hyoscine  (scopolamine)  except  that  it  relieved  pain  and 
served  to  bridge  the  patient  over  a  period  during  which 
he  would  suffer  intensely  without  it.  It  was  claimed  for 
it  that  by  preventing  the  suffering  during  this  period  it 
protected  the  patient  from  undue  nerve  strain  and  from 
the  exhaustion  incident  to  the  withdrawal  of  opiates ;  also 
that  it  aroused  certain  nerve-centers  which  the  opiate 
had  blunted. 

To  these  three  claims  we  might  add  that  of  secondary 
stimulation  of  the  secreting  and  excreting  organs.  In 
these  particulars  and  to  this  extent  hyoscine  (scopo- 
lamine) is  a  curative  remedy  in  drug  addiction,  but  it  is 
not,  in  the  opinion  of  the  author,  curative  in  any  other 
sense. 

Soon  after  the  appearance  of  the  author's  first  article, 
in  which  he  brought  hyoscine  (scopolamine)  to  the  atten- 
tion of  the  profession  as  a  useful  remedy  in  the  treatment 
of  morphinism,  Lott,  of  Texas,  published  an  article  on 


Lott's  Erroneous  Claims.  73 

the  treatment  of  drug  habits  (addiction)  in  which  he 
made  extravagant  claims  for  hyoscine. 

He  brought  hyoscine  forward  as  an  antidote  for 
morphine,  claiming  it  to  be  "a  specific  cure  of  the  mor- 
phine habit." 

In  his  article  he  says  that  he  can  give  no  explanation 
of  its  curative  effects,  but,  depending  upon  the  empirical 
experience  acquired  in  the  treatment  of  25  cases,  he 
makes  the  assertion  that  it  is  "an  antidote  for  morphine" 
and  insists  on  its  free  administration,  believing  it  to  be 
the  sole  curative  agent. 

He  says  this  cure  is  effected  without  pain.  That  it 
may  be  seen  how  painless  a  cure  of  the  morphine  addic- 
tion is  when  hyoscine  is  depended  upon  as  the  sole 
curative  agent,  the  author  will  quote  from  Lott's  paper. 
He  says: — 

"In  treating  for  opium  or  any  of  its  preparations  there  should 
be  nothing  given  to  cause  the  bowel  to  move,  for  as  soon  as  the 
morphine  is  out  of  him,  during  his  second  day,  a  bilious  diarrhea 
sets  in  that  will  worry  the  patient  a  good  deal." 

Of  the  condition  of  the  patient  at  the  end  of  the 
period  during  which  he  gives  hyoscine,  Lott  says : — 

"Thus  far  all  is  well,  the  patient  has  been  relieved  from  the 
drug,  but  he  is  not  cured.  It  will  take  him  a  long  time  before 
his  cure  is  completed  and  often  his  courage  and  fortitude  is  taxed 
to  the  utmost.  It  is  true  he  has  escaped  from  morphine  without 
pain,  but  he  will  not  be  able  to  rebuild  the  shattered  constitution 
without  more  or  less  suffering.  The  functions  of  the  body  so 
necessary  to  health  having  been  impaired,  appetite,  digestion, 
assimilation,  sleep,  proper  equipoise  of  the  nervous  system  are  to 
be  restored.  Not  only  so,  but  often  for  the  first  week,  or  for  that 
matter  the  first  month,  there  is  pain  in  the  back  and  knees,  feet 
and  arms,  sometimes  quite  severe." 


74  Narcotic  Drug  Diseases  and  Allied  Ailments. 

This  does  not  sound  to  the  author  as  if  the  patient 
had  been  "cured  without  pain."  While  the  doctor  says, 
"The  patient  has  escaped  from  morphine  without  pain," 
we  ask  the  question:  Is  it  possible  that,  while  he  was 
escaping,  some  other  blighting  disease  fastens  itself  upon 
him  and  is  the  cause  of  all  this  suffering? 

Or,  can  all  this  pain  and  discomfort  be  a  necessary 
part  of  the  reconstructive  process  that  lies  out  before 
him?  Is  the  reconstructive  process  a  painful  one?  Not 
so,  but  with  all  charity  it  must  be  said  that  the  marked 
discomfort  of  the  patient  is  mainly  due  to  the  neglect  by 
his  physician  of  one  of  the  fundamental  doctrines  of 
medical  science,  that  is,  that  retained  excrementitious 
matter  greatly  aggravates  and  intensifies  any  disorder 
to  which  the  human  economy  is  liable,  and  that  its 
removal  is  the  first  and  often  the  most  essential  step  in 
treatment. 

Following  the  teachings  of  Lott,  Behring,  Stockard, 
and  others  have  written  articles  advocating  the  use  of 
hyoscine  (scopolamine),  insisting  that  it  is  "a  specific 
cure  of  the  morphine"  addiction.  Behring  claims  that  it 
is  as  much  of  a  "specific  for  morphinism"  as  "quinine  is 
to  malaria." 

Some  of  these  writers  give  Lott  credit  for  first  bring- 
ing it  to  the  attention  of  the  profession  as  a  means  of 
controlling  the  suffering  incident  to  the  abrupt  with- 
drawal of  opiates;  but  as  the  author's  paper  appeared 
before  that  of  Lott,  it  is  evident  that  this  claim  is 
erroneous. 

However,  the  author  has  never  claimed  hyoscine 
(scopolamine)  to  be  a  specific  cure  for  the  morphine 
addiction  (disease).  He  does  insist  that  it  is  a  useful 
remedy.  He  claims  that  no  remedy  for  any  disease 
gives  better  results  than  hyoscine  (scopolamine)  in  the 


Hyoscine,  Office  and  Value  of.  75 

treatment  of  morphinism,  but  the  fact  that  it  meets 
certain  indications  in  the  treatment  does  not,  in  any 
sense,  make  it  a  specific  cure  for  this  ailment. 

The  gradual  reduction  method  of  treating  morphin- 
ism should  be  discarded  as  useless,  and  even  hurtful ;  the 
sudden  withdrawal  without  some  agent  to  relieve  the 
patient's  suffering  is  inhumane  and  dangerous.  This 
leaves  the  rapid  reduction  as  the  only  one  of  the  old 
methods  worthy  of  consideration ;  but  in  this  the  patient 
suffers  so  intensely  and  the  result  is  so  seldom  a  cure 
that  it  certainly  cannot  be  regarded  as  a  satisfactory  or 
successful  treatment.  Any  remedy  or  course  of  treat- 
ment capable  of  robbing  the  sudden  withdrawal  of  mor- 
phine of  its  horrors  of  suffering  and  dangers  to  life 
should  be  regarded  as  a  Godsend  to  humanity. 

After  the  patient  is  prepared  for  it,  the  discreet  ad- 
ministration of  hyoscine  accomplishes  this  result. 

The  painful  symptoms  incident  to  the  abrupt  with- 
drawal of  morphine  have  a  natural  limit  of  a  few  days' 
duration.  By  the  discreet  administration  of  hyoscine 
(scopolamine)  these  days  may  be  passed  in  comfort  and 
the  patient  thereby  be  protected  from  the  nerve  strain 
and  shock  which  would  otherwise  attend  such  an  ordeal 
of  suffering. 

Hyoscine  (scopolamine)  not  only  occupies,  but  fills, 
when  properly  used,  as  important  a  place  in  the  treat- 
ment of  morphinism  as  does  chloroform  or  ether  in  the 
practice  of  surgery.  Its  office  is  very  similar  to  theirs. 
It  saves  the  patient  from  indescribable  suffering  and 
renders  the  unsafe,  impracticable,  and  difficult,  safe, 
practicable,  and  easy. 

But  the  principal  curative  agents  are  the  purgatives 
given  at  the  beginning  of  the  treatment.  Without  thor- 
ough elimination  the  hyoscine  (scopolamine)  does  not 


76  Narcotic  Drug  Diseases  and  Allied  Ailments. 

cure  or  bring  relief  to  the  patient  to  such  a  degree  as  to 
enable  him  to  recover  his  health. 

Any  course  of  treatment  which,  afterward,  involves 
such  protracted  suffering  as  is  involved  in  the  with- 
drawal of  morphine  when  hyoscine  (scopolamine)  alone 
is  depended  upon  to  effect  the  cure  is  unreasonable,  and 
must  necessarily  be  unsuccessful. 

The  diarrhea,  nervousness,  sleeplessness,  absence  of 
appetite,  and  the  numerous  nervous  symptoms  which 
necessarily  grow  out  of  the  poisoned  condition  of  the 
system  are  such  as  to  break  down  the  strongest  person. 
Before  the  system  can  right  itself  by  nature's  efforts 
unaided  this  ordeal  of  suffering  brings  the  patient  to  the 
point  of  desperation,  and  in  this  desperate  state  resort 
is  made  to  some  pain-relieving  drug  and  this  usually 
arrests  the  convalescence.  In  order  to  cure  these 
patients,  in  fact,  to  cure  any  disease,  the  cause  must  be 
removed. 

The  extremely  toxic  condition  of  the  system  is  the 
principal  cause  of  suffering  in  these  cases.  When  this 
toxic  state  is  overcome  by  a  properly  directed  course  of 
elimination,  then  hyoscine  (scopolamine)  plays  its  role 
as  an  aid  to  help  bridge  over  a  period  which  it  would  be 
extremely  difficult  to  pass  without  it.  This  is  enough  to 
claim  for  any  remedy  and  it  is  all  the  author  feels  that 
anyone  should  claim  for  this  one. 

Hare,  at  one  time,  was  led  to  make  excessive  claims 
for  the  effects  of  hyoscine  (scopolamine).  In  comment- 
ing upon  the  article  of  Lott,  Hare  says,  "A  patient  can 
take  massive  doses  of  hyoscine  (scopolamine)  for  days 
at  a  time,  as  much  an  one  quarter  of  a  grain  per  day, 
without  evil  effect  on  any  of  the  vital  functions."  He 
further  notes  the  fact  that  the  administration  of  hyoscine 
(scopolamine)  overcomes  the  craving  for  morphine. 


Hyoscine,  Not  Specific  Cure.  77 

The  author,  at  that  time,  called  attention  to  the  lack 
of  conservatism  in  this  statement  and  pointed  out  the 
dangers  which  would  be  likely  to  follow  its  adoption, 
noting  especially  that  it  would  be  dangerous  to  give  a 
patient  who  is  addicted  to  any  form  of  alcoholism  M.OO 
grain  of  hyoscine  (scopolamine)  every  hour  for  days  at 
a  time. 

These  rash  claims  for  hyoscine  (scopolamine)  have 
led  to  the  indiscreet  and  unnecessarily  free  use  of  this 
agent  and  have  brought  it  into  disrepute  in  the  hands  of 
many  good  men. 

These  results  were  not  the  fault  of  the  remedy,  but 
were  due  to  its  being  administered  to  persons  who  had 
not  been  put  in  condition  to  take  it  without  untoward 
effects  and  to  its  excessive  administration. 

Believing  hyoscine  (scopolamine)  to  be  a  specific 
cure  for  the  morphine  addiction,  it  was  given  with  the 
idea  that  it  cured,  and  this  led  to  its  administration  being 
pushed,  in  some  cases,  out  of  all  reason. 

The  author  reviewed  the  papers  of  Lott  and  Hare 
soon  after  their  appearance.  The  comment  then  made  is 
still  pertinent  and  it  is  here,  in  part,  reproduced.  Two 
articles  have  appeared  in  medical  literature  that  deserve 
particular  attention  and  invite  some  criticism.  One  of 
them  is  from  the  gifted  pen  of  H.  A.  Hare,  entitled  "A 
New  Method  of  Treating  the  Morphin  and  Alcohol 
Habits" ;  it  was  published  in  the  Medical  News  on  June 
7,  1902.  The  other,  treating  of  "The  Drug  Habit  and 
its  Cure  without  Pain,"  is  by  M.  K.  Lott,  of  Cameron, 
Texas.  This  was  published  in  Therapeutic  Gazette, 
Feb.,  1902. 

These  articles  are  both  on  the  use  of  hyoscine  (scopo- 
lamine) for  the  treatment  of  drug  and  liquor  addiction, 
and  are  valuable  contributions  to  our  literature.  At  the 


78  Narcotic  Drug  Diseases  and  Allied  Ailments. 

same  time,  they  contain  certain  statements  which,  to  say 
nothing  worse,  are  likely  to  impair  their  usefulness. 

Lott  reports  the  treatment  of  a  series  of  cases  of 
morphine  and  whisky  addiction  with  hyoscine,  and  Hare 
says : — 

"I  have  tried  this  plan  in  6  cases  with  extraordinary  results, 
from  the  following  points  of  view: — 

"i.  The  patient  can  take  massive  doses  of  hyoscine  for  days 
at  a  time,  as  much  as  one-fourth  of  a  grain  each  day,  hypoder- 
mically,  with  no  evil  effect  on  any  vital  function. 

"2.  They  suffer  very  little,  if  at  all,  from  the  immediate  with- 
drawal of  morphine. 

"3.  And  more  surprising,  the  desire  for  the  drug  is  largely, 
if  not  entirely,  dissipated  after  a  few  days." 

While  the  author  can  confirm  the  second  and  third 
of  these  statements,  it  is  evident  that  the  first  is  so  broad 
and  sweeping  that  it  should  not  go  without  challenge, 
since,  if  it  were  followed,  it  would  inevitably  result  disas- 
trously and  soon  bring  a  most  valuable  plan  of  treatment 
into  disrepute,  if  not  into  round  condemnation. 

This  comment  was  made  at  the  time  and  the  predic- 
tions have  proven  true.  It  is  unfortunate  that  such 
a  statement  should  have  been  made  by  one  occupying  the 
position  and  speaking  with  such  authority  as  does  Hare. 

One-fourth  grain  of  hyoscine  (scopolamine)  admin- 
istered in  twenty-four  hours  is  a  little  more  than  Vioo 
grain  each  hour. 

The  author  has  had  quite  an  extensive  experience 
with  this  drug  and  has  watched  its  effects  very  closely. 
During  the  last  twelve  years  the  author  has  treated  more 
than  3000  cases  of  narcotic  addiction  in  which  hyoscine 
(scopolamine)  has  been  used  freely,  and,  basing  an 
opinion  upon  that  experience,  is  prepared  to  say  that 


Hare's  Inadvertent  Claim.  79 

there  are  many  more  people  who  cannot  safely  take  YIQQ 
grain  of  hyoscine  (scopolamine)  every  hour  for  days  at 
a  time  than  there  are  who  can,  with  safety,  take  that 
quantity;  and,  that  such  dosage,  routinely  administered, 
as  advised  by  these  gentlemen  would  frequently  prove 
fatal. 

The  effects  of  no  other  drug  in  our  entire  materia 
medica  vary  so  greatly  with  different  individuals  as  do 
those  of  the  belladonna  group  of  remedies :  none  require 
such  close  and  discriminating  care  in  their  adminis- 
tration. 

To  illustrate  the  wide  differences  in  the  effects  of 
these  drugs  on  different  individuals,  and  to  show  that 
their  prolonged  administration  in  the  treatment  of  mor- 
phinism is  not  necessary,  clinical  notes  of  a  few  cases  are 
given  in  the  following  chapter, 


CHAPTER  IV. 

TREATMENT  (CONTINUED). 


CASE   REPORTS,   ETC. 

CASE  I. — Mrs.  B.,  aged  52  years;  weight,  140  pounds,  had  a 
morphine  habit  of  fifteen  years'  standing.  Her  daily  quantity 
was  10  grains  taken  by  mouth  in  two  doses.  She  came  for  treat- 
ment October  9,  1899.  The  usual  dose  of  morphine  was  given  at 

3  P.M.     Patient  received  a  Turkish  bath,  was  deprived  of  her 
supply  of  morphine,  and  placed  in  room  specially  prepared  for 
her,  with  a  trained  nurse  in  constant  attendance.     From  4  to  10 
P.M.,  purgative  course  of  calomel,  cascara,  strychnine,  and  ipecac 
was  given. 

The  next  morning  this  was  followed  by  a  full  dose  of  castor 
oil,  and  later  by  a  bottle  of  citrate  of  magnesia,  from  which  the 
bowels  were  thoroughly  emptied  by  8  A.M.  The  bowels  having 
acted  freely,  there  was  no  demand  for  morphine  until  2  P.M.,  at 
which  time  she  said  she  was  nervous  and  aching  and  wanted  a 
dose  of  her  drug.  At  that  time  her  pulse  was  65,  full,  and 
regular;  respiration,  18;  skin  moist,  but  not  sweating.  At  2  P.M., 
she  was  given  %00  grain  of  hyoscine,  repeating  the  dose  at  3  and 

4  P.M. 

The  author  then  left  the  patient,  expecting  to  return  in  two 
hours,  but  shortly  before  that  time  had  expired  he  was  hastily 
called  to  see  her.  He  found  her  profoundly  narcotized,  breathing 
stertorously  8  to  12  per  minute,  with  lower  jaw  dropped,  skin 
bathed  in  perspiration,  pulse  40  to  50  and  irregular.  She  could 
not  be  aroused  to  any  degree  of  consciousness. 

The  administration  of  restoratives,  such  as  caffeine,  strych- 
nine, nitroglycerin,  hot  applications  to  spine,  etc.,  was  at  once 
begun,  and  was  continued  for  three  hours.  At  times  there  seemed 
(80) 


Toxic  Effect  of  Hyoscine.  81 

to  be  some  improvement,  but  soon  these  signs  would  disappear, 
and  at  the  end  of  the  third  hour  of  these  efforts  her  condition 
was  decidedly  more  perilous.  Patient  very  much  cyanosed; 
breathing  more  irregular  and  only  6  to  8  per  minute ;  pulse  more 
irregular  and  of  less  volume. 

At  times  responding  to  the  stimulants,  the  pulse  would  run 
up  to  60  or  70  to  the  minute,  and  would  then  drop  back  to  a 
much  slower  rate,  at  one  time  being  as  low  as  38  per  minute.  It 
seemed  that  all  remedies  at  hand  were  failing,  and  that  the  patient 
would  die  in  spite  of  all  efforts  to  save  her. 

The  excessive  diaphoresis  and  failing  pulse  volume  suggested 
the  possible  efficiency  of  saline  solution.  One  quart  of  normal 
salt  solution  was  injected  into  the  cellular  tissues,  and  the  same 
quantity  into  the  bowel  with  a  colon-tube.  In  less  than  thirty 
minutes  there  were  distinct  signs  of  improvement;  within  an 
hour  her  breathing  was  fairly  good,  12  to  the  minute;  cyanosis 
had  disappeared;  pulse  was  50  and  of  fair  volume;  sweating  less 
profuse,  and  the  extreme  prostration  had  given  way  to  a  condition 
of  fair  tone.  Her  condition  gradually  became  more  normal.  In 
three  hours  from  the  time  the  first  salt  solution  was  given  it  was 
repeated,  and  she  was  allowed  to  continue  to  sleep  without  efforts 
to  arouse  her. 

From  this  time  on,  her  condition  was  satisfactory ;  sleep  was 
a  little  more  profound  than  natural,  but  respiration  and  circula- 
tion were  good.  Sixteen  hours  from  the  time  the  last  dose  of 
hyoscine  was  given  she  awoke  voluntarily,  but  was  languid  and 
drowsy  for  several  hours  more.  At  the  end  of  this  time  she 
began  to  complain  of  pain  in  her  back  and  limbs.  One  two- 
hundredth  grain  of  hyoscine  was  given,  and  the  dose  was  re- 
peated in  thirty  minutes. 

This  gave  relief  which  continued  for  a  period  of  six  hours, 
when  the  limbs  were  again  uncomfortable.  She  said  she  had  no 
desire  for  morphine,  but  would  like  to  have  something  to  stop 
the  aching  in  her  legs.  One  one-hundred  and  fiftieth  grain  of 


82  Narcotic  Drug  Diseases  and  Allied  Ailments. 

hyoscine  was  given.  This  brought  complete  relief,  and  when  the 
effects  of  this  had  subsided  the  pain  did  not  return. 

Not  another  dose  of  medicine  of  any  kind  was  given  in  the 
case.  She  had  no  desire  for  morphine  or  any  other  stimulant, 
but  expressed  herself  as  feeling  well  and  desired  something  to 
eat.  Liquid  nourishment  was  given  and  retained,  and  within 
three  days  she  was  eating  heartily  and  said  she  enjoyed  her  food 
more  than  she  ever  had  done  before. 

At  that  time  to  the  author  the  most  remarkable  feature  of 
this  case  was  the  fact  that  she  could  sleep  from  five  to  seven 
hours  every  night  and  then  frequently  take  a  nap  of  an  hour  or 
more  during  the  day.  She  made  an  uneventful  and  rapid  re- 
covery, gained  30  pounds  in  flesh  in  four  months,  and  has 
remained  free  from  the  morphine  addiction  from  that  day  to  this. 

Her  husband  says  that,  instead  of  her  former  sedentary  and 
seclusive  habits,  she  now  wants  to  be  up  and  going  all  the  time, 
and  would  not  willingly  take  a  dose  of  morphine  even  to  save 

her  own  life. 

i 

There  is  little  doubt  that  this  patient  would  have  died 
from  the  effects  of  the  three  Vice-grain  doses  of  hyoscine 
given  her  had  it  not  been  for  the  happy  effect  of  the 
normal  salt  solution.  It  evidently  saved  her  life  by  in- 
creasing the  volume  of  the  circulating  medium  and  by 
rendering  less  concentrated  the  narcotic  poison  it  held. 

The  writer  has  had  quite  a  number  of  patients  who 
were  extremely  sensitive  to  the  effects  of  hyoscine,  but 
the  following  case  shows,  about  as  marked  intolerance  as 
any: — 

CASE  II. — Mrs.  E.  D.,  aged  30  years,  blonde,  weight  125 
pounds,  had  a  morphine  habit  of  thirteen  years'  standing,  her 
daily  quantity  being  20  grains  taken  hypodermically  in  three 
doses.  From  4  to  10  P.M.,  July  27,  1901,  a  mercurial  and  vege- 
table cathartic  was  administered ;  also  a  vapor  bath. 


Hyoscine,  Intolerance  for.  83 

The  last  morphine,  7  grains,  was  allowed  at  6  P.M.  At  7 
o'clock  the  following  morning,  2  ounces  of  castor  oil  were  given, 
followed  two  hours  later  by  a  bottle  of  citrate  of  magnesia. 
The  bowels  began  to  act  at  5  A.M.,  and  between  that  time  and 
noon  six  free  evacuations  occurred.  Patient  was  fairly  com- 
fortable during  the  time,  and  did  not  ask  for  her  drug  until  noon. 

At  12.25  P-M-  she  was  given  %50  grain  of  hyoscine  and  I 
grain  of  sparteine.  In  thirty  minutes  the  patient  was  asleep,  and 
she  slept  an  hour.  Face  was  deeply  flushed;  respiration  and 
circulation  slightly  accelerated.  She  awoke  at  2  P.M.,  when  her 
mind  was  clear.  Then  she  complained  of  aching  of  limbs. 

At  2  P.M.  she  was  given  %oo  grain  of  hyoscine,  after  which 
she  fell  asleep  again,  and  slept  about  an  hour.  On  waking,  her 
mind  was  wandering,  and  she  continued  in  a  mild,  loquacious 
delirium  until  6  P.M.,  when  the  mind  began  to  clear,  and  as  con- 
sciousness returned  she  said  she  was  uncomfortable. 

At  9  P.M.  she  was  again  given  %50  grain  of  hyoscine. 
Delirium  was  fully  re-established  in  thirty  minutes,  and  for  sev- 
eral hours  it  was  of  a  more  marked  type,  continuing  without 
material  abatement  until  6.30  A.M.  At  that  time  she  was  in  a 
measure  conscious,  complained  of  some  discomfort,  and  said  she 
would  take  morphine  if  she  had  it. 

At  7  A.M.,  July  2Qth,  %00  grain  of  hyoscine  and  I  grain  of 
sparteine  were  given.  Delirium  recurred  in  a  short  time,  con- 
tinuing without  any  sign  of  abatement  during  the  entire  day,  and 
even  the  next  morning,  twenty-four  hours  after  the  last  dose  of 
hyoscine  had  been  given,  her  mind  was  not  entirely  clear.  Dur- 
ing this  time,  although  she  had  some  lucid  moments,  she  did  not 
complain  of  any  pain  or  discomfort  whatever,  and  said  she  had 
no  desire  for  morphine.  No  medicines  of  any  kind  were  given 
during  this  day. 

July  3Oth,  the  fourth  from  the  beginning  of  treatment,  she 
took  liquid  nourishment,  suffered  no  pain  or  even  discomfort, 
showed  no  abstinence  symptoms  of  any  kind,  and,  while  she  said 


84  Narcotic  Drug  Diseases  and  Allied  Ailments. 

she  felt  weak,  she  had  no  desire  for  morphine.  A  bath  was  given 
morning  and  evening,  she  sat  up  most  of  the  day,  and  slept  be- 
tween four  and  five  hours  that  night  without  medicine  of  any 
kind,  nor  did  she  sleep  less  than  that  any  night  thereafter.  She 
remained  in  the  institution  three  weeks.  By  the  end  of  the  first 
week  her  appetite  was  ravenous;  she  could  eat  with  impunity 
anything  she  was  allowed ;  had  no  diarrhea  or  other  complication, 
and  gained  flesh  at  the  rate  of  ^  pound  a  day.  At  the  end  of  the 
third  week  she  was  discharged,  looking  like  an  entirely  different 
woman.  At  no  time  had  she  any  desire  for  morphine,  nor  did 
she  show  any  inclination  to  take  other  stimulants. 

This  case  is  remarkable  because  of  the  extremely 
small  quantity  of  hyoscine  required  to  bring  the  patient 
well  under  its  influence,  and  for  the  length  of  time  the 
effects  of  the  drug  continued.  This  patient  would  most 
likely  have  been  made  violently  delirious,  and  probably 
thrown  into  convulsions,  from  cerebral  congestion,  or 
have  been  dangerously  narcotized,  by  the  administration 
of  %oo  grain  of  hyoscine  every  hour  for  even  three  or 
four  hours  in  succession,  not  to  speak  of  several  days. 

These  two  cases  show  the  marked  susceptibility  of 
some  people  for  hyoscine,  and  that  the  routine  or  careless 
administration  of  that  drug  is  an  extremely  hazardous 
procedure. 

There  are  others  who  have  an  unnatural  tolerance 
for  this  drug.  The  following  case  shows  remarkable 
tolerance : — 

CASE  III. — Mrs.  T.  N.,  a  blonde,  aged  25  years,  weight  120 
pounds,  five  feet  four  inches  in  height,  compactly  built,  was  of  a 
sensitive,  nervous  temperament.  Her  morphine  habit  was  of 
four  years'  standing,  and  the  daily  quantity  taken  was  10  grains 
hypodermically,  in  four  or  five  doses. 


Hyoscine,  Unusual  Tolerance  for.  85 

March  2,  1902,  4  to  10  P.M.  Active  purgative  course  of 
calomel,  cascara,  strychnine,  and  ipecac.  Last  morphine,  2% 
grains,  at  9  P.M.  Vapor  bath. 

March  3d,  5  A.M.  Bottle  citrate  magnesia. 

7  A.M.  Bowels  have  acted  several  times,  but  character  of 
actions  not  altogether  satisfactory.     Is  suffering  and  wants  mor- 
phine.    7  A.M.  Gave  l/20o  grain  hyoscine. 

7.30  A.M.  Gave  y20o  grain  of  hyoscine. 

8  A.M.  Gave  %0o  grain  hyoscine. 

9  A.M.  No  perceptible  effect  from  doses  given.    9  A.M.  Gave 
%5  grain  hyoscine. 

9.30  A.M.  Gave  %0  grain  hyoscine. 

10  A.M.   Very   little   effect   from   preceding  doses.     Mouth 
slightly  dry;  is  still  suffering.     10  A.M.  Gave  %0  grain  hyoscine. 

11  A.M.  Gave  %o  grain  hyoscine.     Slept  two  hours;   face 
flushed;  mind  clear;  pulse  and  respiration  slightly  accelerated. 

2  P.M.  Gave  1/25  grain  hyoscine.  Slept  three  hours;  com- 
fortable. 

5.50  P.M.  Gave  y25  grain  hyoscine. 

7  P.M.  Gave  %0  grain  hyoscine.    Uncomfortable. 

9  P.M.  Gave  %5  grain  hyoscine. 

12  P.M.  Gave  y25  grain  hyoscine. 

March  4th,  4  A.M.  Gave  ^95  grain  hyoscine. 

7  A.M.  Gave  %0  grain  hyoscine. 
7.45  A.M.  Gave  y>5  grain  hyoscine. 
8.30  A.M.  Gave  y25  grain  hyoscine. 

From  5.50  P.M.  to  8.30  A.M.  was  quiet,  but  not  entirely  com- 
fortable, sleeping  at  intervals ;  mind  clear  up  to  9  A.M. 

From  9  A.M.  to  noon  mind  wandered  slightly,  a  very  mild 
delirium,  but  at  other  times  was  entirely  clear.  Did  not  com- 
plain of  discomfort  until  I  P.M. 

i  P.M.  Gave  y25  grain  hyoscine.  Quiet  and  comfortable  till 
8  P.M. 

8  P.M.  Gave  %5  grain  hyoscine.     Nauseated. 


86  Narcotic  Drug  Diseases  and  Allied  Ailments. 

9  P.M.  Gave  %5  grain  hyoscine.     Slept  two  hours. 

March  5th,  I  A.M.  Gave  l/>0  grain  hyoscine.  Slept  three 
hours,  and  on  waking  mind  was  clear.  Was  comfortable;  pulse 
60,  good  volume;  respiration  20;  temperature  normal;  skin 
moist.  Craved  lemonade  and  buttermilk,  which  were  given,  but 
vomited  after  an  hour  or  so,  and  nausea  continued  most  of  the 
day.  Vomited  matter  was  green  and  offensive.  As  the  day 
advanced  she  became  more  nervous  and  uncomfortable. 

The  bowels  not  having  acted  for  thirty-six  hours,  and  not 
very  satisfactorily  at  the  beginning  of  the  treatment,  30  grains  of 
hyposulphite  of  soda  were  given,  and  repeated  every  hour  for 
four  hours.  The  bowels  then  began  to  act,  and  a  number  of  free 
bilious  actions  occurred.  Nausea  then  ceased ;  there  was  no  fur- 
ther marked  discomfort  in  the  case,  and  she  made  an  uninter- 
rupted recovery,  never  at  any  time  expressing  any  desire  for 
morphine,  nor  was  that  or  any  other  medicine  given.  The  bowels 
acted  two  or  three  times  during  each  twenty-four  hours,  but  no 
diarrhea  or  other  complications  occurred. 

She  did  not  sleep  more  than  two  or  three  hours  at  night  for 
the  first  few  nights,  but  gradually  improved  in  that  respect  until 
at  the  end  of  ten  days  she  was  sleeping  five  to  six  hours  out  of 
the  twenty-four  daily. 

The  author  can  give  no  explanation  of  this  patient's 
extreme  tolerance  for  hyoscine.  She  had  never  taken 
hyoscine  or  any  drug  of  that  class  with  her  morphine. 
She  had  been  treated  for  morphine  addiction  about  a 
year  before  she  came  to  the  author.  She  said  that  the 
physician  who  treated  her  said  he  had  given  her  very 
large  doses  of  hyoscine,  but  was  never  able  to  bring  her 
under  its  influence  sufficiently  to  keep  her  from  suffer- 
ing, and  for  that  reason  the  treatment  was  abandoned 
and  the  use  of  the  opiate  resumed. 

The  author  has  had  one  other  case  that  showed  as 
great  or  even  greater  tolerance  for  hyoscine  than  this 


Hyoscine,  Time  and  Extent  of  Administration.          87 

one;  but  that  patient  had  been  taking  an  advertised 
"cure"  for  morphinism  for  several  months  and  there  is 
reason  to  believe  that  one  of  its  ingredients  was  hyo- 
scine.  Large  doses  of  hyoscine  had  no  perceptible  effect 
on  him,  and,  after  trying  them  until  the  writer  was  fully 
satisfied  that  he  was  a  hyoscine  habitue,  a  different  line 
of  treatment  was  adopted,  to  which  he  responded 
normally. 

In  the  sixth  case  reported  by  Hare,  he  says  that  ten 
days  after  the  beginning  of  treatment  "the  patient,  while 
still  receiving  these  massive  doses  of  hyoscine,  began  to 
pass  from  under  their  influence,  her  tongue  was  moist, 
her  mind  clear,"  etc. 

It  is  evident  that  in  this  case  the  morphine  habit  had 
been  supplanted  by  the  hyoscine  habit.  This  patient  was 
still  receiving  doses  of  this  drug  when  the  case  was  re- 
ported. From  the  course  pursued  in  the  first  case 
reported  by  him,  the  author  presumed  that  this  drug  was 
to  be  discontinued  by  gradual  withdrawal. 

In  this  connection  the  author  enters  a  protest  against 
such  a  procedure,  and  reminds  the  profession  that  there 
is  nothing  in  this  condition  or  in  the  nature  of  this  drug 
to  warrant  the  belief  that  the  method  of  gradual  reduc- 
tion would  be  more  successful  as  a  treatment  for  the 
hyoscine  habit  than  it  has  been  for  the  morphine  habit, 
in  which  it  has  been  a  stupendous  failure. 

If  the  example  of  Dr.  Hare  in  giving  hyoscine  two 
weeks  or  longer,  until  tolerance  for  it  is  established,  is 
followed,  the  hyoscine  habit  will  soon  be  another  curse 
with  which  unfortunate  victims  will  have  to  contend. 

There  is  no  reason  whatever  for  the  administration 
of  hyoscine  in  a  morphine  case  for  a  longer  period  than 
two  or  four  days,  so  far  as  the  cure  of  that  addiction  is 
concerned.  Forty-eight  hours  should  be  the  extreme 


88  Narcotic  Drug  Diseases  and  Allied  Ailments. 

limit  as  a  rule,  and  that  is  longer  than  is  necessary  in 
most  cases. 

In  an  article  published  in  the  October,  1901,  number 
of  the  Therapeutic  Gazette  the  author  contended  for  the 
following  propositions : — 

That  abstinence  symptoms,  or  the  various  manifesta- 
tions thus  designated,  which  occur  upon  the  withdrawal 
of  morphine,  are  due  mainly  to  intoxication  from  effete 
material  locked  up  in  the  system  by  the  effects  of  mor- 
phine, and  to  the  secondary  effect  of  that  drug. 

That  when  a  primary  step  in  the  treatment  is  thor- 
ough elimination  of  both  the  stored-up  drug  and  the 
effete  material  with  which  these  patients  are  surcharged, 
the  most  distressing  and  dangerous  symptoms  met  upon 
withdrawal  are  avoided ;  that  if  the  system  is  thoroughly 
freed  from  effete  material,  and  morphine  discontinued, 
all  distressing  painful  symptoms  subside  within  three 
days — as  soon  as  the  secondary  effects  of  morphine  are 
exhausted — without  further  treatment  of  any  kind. 

And  that  the  essential  office  of  hyoscine  in  the  treat- 
ment of  this  ailment  is  to  keep  the  patient  from  suffering 
during  that  interval;  that  as  a  rule  all  medication  can  and 
should  be  discontinued  within  four  or  five  days. 

Dr.  Hare  ignores  these  contentions  altogether,  and 
Dr.  Lott  takes  a  different  position.  He  says :  "In  treat- 
ing for  opium  or  any  of  its  preparations,  there  should  be 
nothing  given  to  cause  the  bowels  to  move,  for  as  soon 
as  the  morphine  is  out  of  him,  during  the  second  day,  a 
bilious  diarrhea  will  set  in  that  will  worry  the  patient 
a  good  deal." 

Thus,  he  waits  for  the  system,  released  from  the 
benumbing  influence  of  morphine,  to  awake  to  the  pres- 
ence of  the  large  accumulation  of  excrementitious  matter 
and  set  up  a  diarrhea  to  throw  it  off,  and  allows  this  to 


Rapid  Gain  in  Flesh  Usual.  89 

occur  when  the  patient,  recently  deprived  of  the  sustain- 
ing power  of  morphine,  is  least  able  to  bear  such  drain. 

But  let  us  see  what  are  some  of  the  other  results  these 
gentlemen  get  from  the  treatment  as  they  give  it,  and 
how  long  they  are  about  it. 

Dr.  Hare  says  of  his  first  case:  "In  this  particular 
case  the  large  doses  of  hyoscine  were  continued  for  a 
period  of  over  two  weeks  and  then  were  gradually  de- 
creased. It  is  now  several  months  since  the  treatment 
ceased,"  and  "I  have  seen  this  patient's  physician  during 
the  last  few  days,  and  he  tells  me  that  not  only  is  the 
man  not  taking  morphine,  but  that  he  seems  to  be 
improved  in  every  way,  and  has  gained  ten  or  twelve 
pounds  in  weight." 

An  average  patient  whose  system  is  put  in  proper 
condition  at  the  beginning  of  treatment,  and  to  whom 
only  what  hyoscine  and  other  medicine  he  needs  is  given, 
will  gain  flesh  at  the  rate  of  %  to  i  pound  per  day  until 
his  full  normal  weight  has  been  reached,  and  his  improve- 
ment in  every  other  respect  is  so  marked  that  the  most 
conservative  physician  will  say  more  than  that  he  "seems 
to  be  improved." 

In  Dr.  Hare's  last  case  he  says :  "Twelve  days  after 
treatment  began  she  asked  for  solid  food."  A  patient 
of  this  class  whose  system  has  been  properly  cleansed 
of  effete  material  and  relieved  from  the  effects  of  auto- 
intoxication at  the  beginning  of  treatment  usually  craves 
solid  food  on  the  fourth  or  fifth  day  thereafter,  and  by 
the  end  of  the  first  week  has  an  appetite  that  would  do 
credit  to  a  fieldhand. 

The  use  of  morphine  interferes  with  the  proper  work- 
ing of  all  excretory  glands,  and  causes  prolonged  reten- 
tion of  the  products  of  waste,  resulting  in  profound 
intestinal  and  auto-  intoxication.  The  effects  of  this  are 


90  Narcotic  Drug  Diseases  and  Allied  Ailments. 

so  manifold  and  far-reaching  that  it  is  almost  beyond 
human  ability  to  enumerate  them. 

Suffice  it  to  say  that  all  the  annoying  and  painful 
symptoms  with  which  Dr.  Lott  says  his  patients  have  to 
contend  are  daily  met  with  and  are  well  understood  to  be 
the  effects  of  systemic  intoxication.  It  is  also  axio- 
matical that  if  the  system  is  not  too  profoundly  impressed 
nature  will  finally  come  to  the  rescue,  and  set  up  a  diar- 
rhea or  other  discharge  to  relieve  the  victim  of  this 
poisonous  matter. 

If  nature  is  better  prepared  to  do  this  unaided  and 
alone  than  by  the  aid  afforded  by  purgatives,  diuretics, 
diaphoretics,  etc.,  skillfully  administered,  then  indeed 
have  the  fathers  in  medicine  striven  in  vain  to  establish 
our  art.  Yet,  notwithstanding  these  fundamental  teach- 
ings, and  notwithstanding  that  Dr.  Lott  recognizes  the 
fact  that  the  system  of  his  patient  is  in  a  condition  in 
which  a  diarrhea  will  soon  be  set  up  to  clear  it  of  offens- 
ive excreta,  he  advises  that  no  purgative  be  given  at  the 
beginning  of  treatment,  but  waits  to  give  nature  a  chance 
to  do  that  work  without  assistance.  This  is  certainly  a 
strange  doctrine,  and  yet  here  we  have  an  eminent  pro- 
fessor of  materia  medica  indorsing  it. 

It  does  seem  strange  that  in  this  age  of  the  world  it 
should  be  necessary  for  anyone  to  insist  that  as  a  primary 
step  in  the  treatment  of  any  disease  the  system  should  be 
cleansed  as  fully  as  possible  of  all  retained  excreta  and 
other  noxious  matter.  The  universally  recognized  value 
of  purgatives  depends  upon  the  fact  that  with  their  aid 
the  system  can  be  more  readily,  perfectly,  and  economic- 
ally cleansed  of  retained  excreta  or  other  offensive 
matter  than  it  can  be  by  a  diarrhea  set  up  by  the  irritat- 
ing action  of  these  substances. 

Diarrhea  thus  induced  often  runs  a  protracted 
course,  and,  if  the  purpose  of  nature  is  ultimately  accom- 


Diarrhea,  Prevention  of.  91 

plished  without  artificial  aid,  it  is  by  the  most  profligate 
expenditure  of  the  patient's  strength  and  other  resources. 
In  Dr.  Lott's  cases,  nothing  so  retards  their  recovery  or 
shatters  their  constitutions  as  does  the  diarrhea. 

In  the  old  methods  of  treatment,  in  which  withdrawal 
of  the  drug  was  attempted  without  preceding  elimina- 
tion, diarrhea  was  one  of  the  most  trying  and  difficult 
complications  to  meet,  and  that  which  most  often  caused 
a  return  to  the  opiate. 

Since  this  diarrhea  can  be  prevented  altogether  by  a 
well-directed  eliminating  course  given  at  the  beginning 
of  treatment,  and  since  this  can  be  given  without  dis- 
comfort, and  when  the  patient  is  still  under  the  sustain- 
ing innuence  of  morphine,  why  should  it  not  be  given? 
Not  only  does  elimination  prevent  the  diarrhea,  but  it 
gives  many  other  advantages. 

For  one  thing,  it  shortens  the  time  during  which  it  is 
necessary  to  give  hyoscine  or  any  other  medicines.  The 
patient,  freed  from  irritating  excrementitious  matter,  is 
far  more  comfortable,  and  has  no  such  array  of  painful 
symptoms  to  contend  with  as  Dr.  Lott  describes. 

In  order  to  show  the  contrast  between  a  case  treated 
with  thorough  elimination  as  the  primary  step  and 
those  reported  by  these  gentlemen,  the  author  will  give 
the  clinical  notes  of  a  case. 

CASE  IV. — Dr.  F.  C,  aged  33  years,  weight  150  pounds, 
nervous  temperament,  began  the  use  of  morphine  in  1898,  and 
gradually  increased  the  quantity  to  10  grains  per  day.  In  August, 
1899,  cocaine  was  added,  and  at  the  time  of  beginning  treatment 
he  was  taking  about  10  grains  of  each  daily,  divided  into  10  to 
15  hypodermic  doses.  He  was  rarely  able  to  get  to  sleep  before 
2  A.M.,  because  of  the  exciting  effects  of  the  cocaine,  which  was 
used  up  to  about  9  P.M.  and  then  discontinued  until  morning.  He 
came  for  treatment  January  9,  1900. 


92  Narcotic  Drug  Diseases  and  Allied  Ailments. 

January  yth.  Gave  a  capsule  containing  2  grains  of  calomel, 
2,  grains  powdered  extract  cascara,  %  grain  strychnine,  and  % 
grain  ipecac  at  4,  6,  8,  and  10  P.M.  The  usual  doses  of  morphine 
and  cocaine  were  allowed  until  9  P.M.,  and  then  discontinued.  At 
this  hour  the  patient  received  a  Turkish  bath. 

January  loth.  Had  a  very  copious  action  from  bowel  at 
5  A.M.,  and  another  at  6.15  A.M. 

At  7  A.M.  gave  3  ounces  of  castor  oil,  and  between  that  time 
and  10  A.M.  had  five  free  bilious  actions  from  bowel.  No  nausea 
or  other  distress  attended  the  action  of  bowel. 

11.30  A.M.  Is  suffering  and  wants  morphine. 

12  M.  Gave  %oo  grain  hyoscine. 

12.15  P'M-  Gave  %QO  grain  hyoscine. 

12.45  P-M-  Gave  %so  grain  hyoscine.  Slept  three  and  a  half 
hours. 

5.25  P.M.  Gave  %5o  grain  hyoscine.  Slept  three  hours;  mind 
clear. 

9  P.M.  Gave  %50  grain  hyoscine.     Suffering. 

9.20  P.M.  ywo  grain  hyoscine. 

9.40  P.M.  yl50  grain  hyoscine.  Slept  three  hours ;  on  waking, 
mind  is  still  clear. 

January  nth,  1.15  A.M.  Gave  %50  grain  hyoscine.    Suffering. 

3.15  A.M.  Gave  Y15o  grain  hyoscine.     More  comfortable. 

5.45  A.M.  Gave  %50  grain  hyoscine.     Mind  still  clear. 

6.20  A.M.  Gave  %0o  grain  hyoscine. 

8.40  A.M.  Gave  ywo  grain  hyoscine.     Comfortable. 

10.40  A.M.  Gave  %oo  grain  hyoscine.     Mild  delirium. 

12.15  P.M.  Gave  %50  grain  hyoscine. 

3  P.M.  Gave  Y150  grain  hyoscine.  Hyoscine  discontinued. 
Delirium  of  mild  type  continued  to  9  P.M.,  at  which  time  the  mind 
was  about  clear.  Comfortable. 

ii  P.M.  Gave  20  grains  of  trional.     Slept  three  hours. 

January  i2th,  9  A.M.  Legs  and  back  aching;  temperature 
99°  F.  Gave  5  grains  each  of  quinine  and  acetanilide  at  9  A.M., 
12  M.,  and  at  3  and  6  P.M.,  but  no  other  medicine. 


Sleep  During  Treatment  Usual.  93 

8  P.M.  Aching  of  legs  and  back  relieved.     Comfortable. 

9  P.M.  Gave  20  grains  of  trional. 

January  i3th,  9  A.M.  Slept  some  last  night,  and  rested  quietly 
during  the  remainder  of  night.  Ate  breakfast  with  relish. 

January  i^th.  Spent  a  comfortable  day  and  night  without 
medicine. 

January  i8th.  The  patient  has  taken  no  medicine  in  last  five 
days  and  nights ;  feels  weak,  but  does  not  suffer  in  any  way ;  has 
no  desire  for  morphine  or  cocaine,  but,  on  the  contrary,  feels 
that  their  effects  would  be  decidedly  unpleasant  to  him  now ;  eats 
heartily,  goes  to  bed  early,  sleeps  soundly  all  night,  and  says  he 
feels  like  a  new  man.  Is  supremely  happy,  since  he  realizes  that 
he  is  no  longer  a  drug  slave.  Placed  in  charge  of  wife  and  sent 
home. 

January  2$th.  At  this  date  the  condition  of  the  patient  may 
be  judged  by  what  his  wife  wrote  to  the  author:  "Doctor  is  doing 
nicely.  If  he  improves  in  the  next  month  as  he  has  this  week  you 
will  not  know  him.  He  sleeps  well  at  night,  gets  up  at  7  o'clock 
every  morning,  and  seems  perfectly  comfortable.  It  seems  so 
strange  to  see  him  up  early  every  morning  now,  for  when  he  was 
taking  drugs  he  could  hardly  be  gotten  out  of  bed  before  noon. 
He  is  eating  heartily,  and  everything  seems  to  agree  with  him. 
His  bowels  have  not  given  him  any  trouble  at  all.  He  says  he 
has  no  desire  for  morphine  or  cocaine,  and  that  he  rarely  thinks 
of  them  now.  He  left  this  morning  for  a  week's  hunt  on  the 
lakes." 

January  $oth.  Patient  visited  the  author  at  his  office.  He 
has  gained  30  pounds  in  weight,  and  looks  like  a  different  man. 
He  feels  a  return  of  his  old-time  energy,  and  is  going  to  make  up 
for  lost  time. 

This  case  is  fairly  typical  of  a  large  percentage  of 
those  treated  by  the  author's  method,  with  the  pos- 
sible exception  that  this  patient,  being  a  morphine  and 
cocaine  habitue,  regained  his  normal  capacity  for  sleep- 


94  Narcotic  Drug  Diseases  and  Allied  Ailments. 

ing  a  little  earlier  than  patients  do  who  have  not  been 
taking  cocaine.  There  is  certainly  no  such  protracted 
painful  convalescence  as  Dr.  Lott  says  his  patients  have. 

He  attributes  these  painful  symptoms  to  the  presence 
of  morphine  in  the  system,  but  in  this  he  is  in  error. 
Morphine  in  the  system  is  not  "the  malady,"  and  is  not 
so  much  to  be  contended  with  as  the  effete  material  which 
it  imprisons  therein. 

Another  statement  by  Dr.  Lott  that  should  be  taken 
with  some  degree  of  allowance  is  this :  "Remember  that 
hyoscine  antidotes  morphine  and  morphine  antidotes 
hyoscine.  If  the  patient  gets  too  much  of  one,  give  the 
other." 

This  statement  is  entirely  too  broad.  It  is  well 
understood  that  hyoscine  and  the  entire  belladonna  series 
are  physiologically  antagonistic  to  morphine  in  a  part  of 
their  range  of  action,  but  it  is  equally  well  established 
that  in  other  respects  they  are  synergistic.  There  is 
certainly  no  chemical  antagonism  between  them;  there- 
fore, to  say  that  they  antidote  one  another  is  misleading. 

They  are  both  hypnotic,  both  anodyne,  and  both 
narcotic,  and  in  these  particulars  they  are  synergistic. 
It  certainly  would  not  have  been  admissible  to  have  given 
the  patient  first  reported  in  this  chapter  morphine  be- 
cause she  had  too  much  hyoscine.  She  was  already 
profoundly  narcotized,  and  morphine  would  have  inten- 
sified that  narcosis. 

There  is  no  doubt  that  many  cases  of  morphine 
poisoning  are  lost  because  of  the  too  free  administration 
of  belladonna  with  the  idea  that  it  is  an  antidote.  It 
certainly  does  not  deserve  to  be  so  classed,  and  neither 
does  hyoscine.  In  some  respects  and  to  a  limited  degree 
they  oppose  each  other,  but  that  is  as  much  as  can  be 
safely  said. 


No  Fixed  Dose  Possible.  95 

In  the  article  referred  to  above  it  is  said :  "Hyoscine 
does  not  materially  affect  the  vital  functions,  or  leave 
after-effects  on  either  the  mind  or  body  of  the  patient; 
therefore,  it  should  be  given  until  its  full  physiological 
effects  are  manifested  if  necessary." 

But  it  is  also  said :  "The  administration  of  this  agent 
should  not  be  left  to  a  nurse,  but  the  physician  should 
remain  with  the  patient  in  person.  The  dosage  in  one 
case  is  no  index  to  what  will  be  required  in  the  next. 
Only  by  the  physician  being  present  and  personally  ob- 
serving the  effects  of  each  dose  can  the  proper  dosage 
be  ascertained  and  the  patient  be  kept  in  a  comfortable 
and  safe  condition." 

The  writer  still  says  that  hyoscine  can  be  safely 
administered  until  its  full  physiological  effects  are  mani- 
fested ;  but  there  is  a  vast  difference  between  the  physio- 
logical or  remedial  effects  of  a  drug  and  its  toxic  effects. 
The  toxic  effects  of  hyoscine  are  dangerous. 

On  account  of  the  great  difference  in  the  suscepti- 
bility of  different  persons  for  this  drug  no  fixed  dosage 
can  be  stated  in  advance,  and  only  by  the  physician 
remaining  with  the  patient  and  watching  the  effects  of 
each  dose,  at  least  until  his  tolerance  or  intolerance  has 
been  ascertained,  can  this  drug  be  used  to  advantage. 

This  precaution  should  be  exercised  in  every  case, 
because  some  persons  are  so  susceptible  to  hyoscine  that 
it  is  a  very  delicate  matter  to  develop  its  physiological 
effects  on  them  without  going  beyond  that  point  and 
getting  its  toxic  effects.  It  cannot  be  administered  in  a 
routine  manner  with  safety. 

Another  peculiarity  of  this  drug,  or  of  persons  taking 
it,  is  that  in  some  cases  prolonged  administration  begets 
intolerance  instead  of  tolerance. 

This  is  rare,  but  in  several  instances  it  has  been 
found  that  after  tEe  patient  had  been  under  the  influence 


96  Narcotic  Drug  Diseases  and  Allied  Ailments. 

of  hyoscine  for  two  or  three  days,  and  after  all  the 
.visible  manifestations  of  the  drug,  except  dilatation  of 
the  pupil,  had  subsided,  a  very  small  dose,  one-fourth  to 
one-half  the  size  of  those  given  in  the  earlier  part  of  the 
administration,  was  sufficient  to  fully  re-establish  the 
effects  of  the  drug,  and  that  the  delirium  induced  by  such 
a  dose  was  more  violent  and  prolonged  than  at  the 
beginning.  In  such  cases  the  prolonged  administration 
would  be  dangerous. 


CHAPTER  V. 

TREATMENT  (CONTINUED). 


CLINICAL  NOTES,  ETC. 

THE  cases  reported  in  the  preceding  chapter,  as  well 
as  the  first  case  reported  in  this  chapter,  were  treated 
during  the  early  years  of  the  author's  experience  in  this 
line  of  work.  A  comparison  of  Case  IV  with  Cases  V 
and  VI,  which  are  also  reported  in  this  chapter,  will 
show  the  difference  between  the  author's  present  method 
and  the  one  used  in  his  earlier  work. 

The  changes  were  made  from  time  to  time  as  clinical 
experiences  pointed  the  way,  and  the  author  feels  confi- 
dent that  each  change  was  an  improvement  and  that  his 
present  method  is  as  complete  and  satisfactory  in  every 
detail  as  the  present  state  of  our  knowledge  will  permit 
of  its  being  made. 

It  will  be  noticed  that  in  Case  IV  the  patient  was 
nauseated  before  the  purgative  began  to  act.  A  number 
of  experiences  such  as  this  led  the  author  to  believe  that 
the  podophyllin  contained  in  the  purgative  compound 
was  the  ingredient  which  was  causing  the  nausea. 

This  ingredient  was  left  out  and  cascara  substituted. 
Patients  taking  this  were  less  inclined  to  be  nauseated. 
Later,  rhubarb  was  discarded,  as  it  also  had  a  tendency 
to  cause  nausea  in  some  cases. 

After  a  careful  trial  of  all  the  purgative  agents  in 
common  use  the  following  were  selected  as  the  agents 
most  suitable  for  administration  in  narcotic  cases: 
calomel,  ext.  cascara,  ipecac,  strychnine,  nit.  atropine 
sulph. 

7  (97) 


98  Narcotic  Drug  Diseases  and  Allied  Ailments. 

It  is  confidently  believed  that  a  combination  of  a 
suitable  quantity  of  these  five  ingredients  makes  a  purga- 
tive compound  which  acts  on  drug  patients  with  the 
greatest  certainty  and  efficiency  and  with  the  least  tend- 
ency to  nausea  or  other  unpleasant  symptoms. 

It  is  a  very  rare  thing  now  for  a  patient  under  the 
author's  care  to  be  nauseated  or  suffer  any  discomfort 
whatever  from  the  effects  of  the  purgative.  A  more  full 
statement  of  his  views  on  the  actions  of  purgatives  is 
given  under  that  head  in  a  later  chapter  of  this  work. 

In  Cases  I,  II,  III,  and  IV  it  will  be  noticed  that  the 
opiate  was  discontinued  at  the  time  of  giving  the  first 
purgative  course,  the  withdrawal  being  abrupt  and 
complete. 

The  treatment  has  been  modified  in  that  particular 
also.  In  the  author's  present  plan  more  time  is  given 
to  the  preparation  of  the  patient  for  the  withdrawal  and 
the  withdrawal  is  made  rapidly,  but  not  at  once. 

Two  or  more  purgative  courses  are  given  and  the 
drug  reduced  materially  following  the  action  of  each 
course,  but  the  final  withdrawal  is  not  made  until  the 
system  has  been  very  thoroughly  cleansed  of  toxic 
matter. 

Since  adopting  this  plan  the  author  has  found  that 
his  patients  suffer  much  less  during  the  treatment,  less 
hyoscine,  daturine,  or  scopolamine  is  required  to  keep 
them  comfortable  during  the  reactionary  period  follow- 
ing the  withdrawal,  delirium  occurs  less  often,  and  when 
it  does  occur  it  is  of  a  milder  type  and  of  shorter  duration. 
The  patient  comes  out  from  the  active  treatment  in 
better  condition  and  the  convalescence  is  more  rapid  and 
is  attended  by  fewer  complications. 

The  blood-pressure  record  and  pulse  tracing  given  in 
Cases  V  and  VI  show  more  clearly  than  words  can  tell 
the  safety  of  the  treatment  as  at  present  administered. 


Defective  Heart  Action  Avoidable.  99 

The  malarial  complication  noted  in  Case  IV  is  one 
which  frequently  occurs  in  patients  who  come  from 
malarial  sections  during  the  late  summer  or  fall  months. 
All  such  cases  should  be  thoroughly  cinchonized  during 
or  immediately  following  the  withdrawal  period. 

Attention  is  called  to  the  effects  of  overtaxing  the 
digestive  organs  both  in  increasing  the  patient's  discom- 
fort and  reducing  his  ability  to  sleep ;  also  to  the  benefi- 
cial effects  of  an  eliminating  course  under  such  cir- 
cumstances. 

The  author  points  to  the  blood-pressure  records  and 
to  pulse  tracings  given  in  the  following  cases  as  most 
convincing  evidence  of  the  correctness  of  his  announce- 
ment, made  eleven  years  ago,  from  clinical  experience 
alone,  without  instrumental  verification,  to  the  effect  that 
"deficient  heart  action  leading  to  collapse  in  these  cases 
is  mainly  due  to  portal  engorgement,  and  that  unloading 
the  intestinal  canal  and  relieving  portal  engorgement 
lessens  the  strain  under  which  the  heart  has  been 
working  more  than  enough  to  compensate  for  the  loss  of 
any  support  it  had  been  receiving  from  the  effects  of  the 
opiate/' 

The  author  has  uniformly  found  high  blood-pressure 
in  morphine  habitues  upon  admission,  but  in  every  in- 
stance unloading  the  portal  system  was  followed  by 
marked  reduction  in  blood-pressure,  usually  amounting 
to  30  to  60  mm.  Hg.  This  reduction  of  arterial  tension 
by  the  preparatory  treatment,  now  instrumentally  veri- 
fied, is  an  essential  factor  in  preventing  collapse  and 
other  dangerous  complications  during  the  withdrawal 
period. 

The  author  does  not  wish  to  be  understood  as  saying 
that  all  morphine  habitues  coming  under  his  care  had 
blood-pressure  higher  than  is  shown  by  the  average 


100  Narcotic  Drug  Diseases  and  Allied  Ailments. 

person  not  taking  morphine,  but  that  in  every  case  in 
which  he  has  made  blood-pressure  tests  the  pressure  was 
found  to  be  higher  in  one  taking  narcotics  than  was 
normal  for  that  particular  person.  The  pressure  in  most 
cases,  however,  was  much  higher  than  the  normal  of  a 
person  of  the  same  age  not  taking  an  opiate. 

Patients  admitted  with  a  blood-pressure  of  180  to  200 
were  usually  found  to  have  a  blood-pressure  of  140  to 
150  after  the  system  had  been  cleansed  of  toxic  matter 
and  the  drug  withdrawn.  This  lowered  record,  being 
maintained  throughout  convalescence,  afterward  showed 
that  it  was  their  normal  blood-pressure  when  not  taking 
an  opiate. 

If  the  patient  upon  admission  had  blood-pressure  of 
1 20  to  140,  as  soon  as  the  system  was  cleansed  of  toxic 
matter  and  the  opiate  withdrawn  the  pressure  would  run 
down  to  90  to  no.  The  fact  that  this  lower  record  per- 
sisted throughout  convalescence  and  after  their  entire 
recovery  shows  that  the  pressure  of  90  to  no  was  the 
normal  blood-pressure,  and  that  the  reading  of  120  to 
140,  while  not  ordinarily  considered  high,  was  higher 
than  normal  for  that  particular  patient. 

CAGE  V. — J.  B.  F.,  admitted  July  i,  1903,  male,  aged  40, 
weight  140,  height  five  feet  ten  inches.  Began  the  use  of  mor- 
phine fifteen  years  ago  during  protracted  illness  (dysentery)  and 
has  used  it  continuously  from  that  time  until  now.  Now  takes 
30  grains  per  day,  hypodermically,  at  five  doses — 6  grains  at  a 
dose,  usually  taken  at  7  and  10  A.M.  and  3,  7,  and  10  P.M. 

Aside  from  a'  loss  of  35  pounds  in  weight,  patient's  general 
health  did  not  seem  to  suffer  much  impairment  from  use  of 
drugs;  he  was  from  a  malarial  section  and  thought  he  suffered 
from  malaria  at  times,  but  did  not  have  chills;  heart,  lungs,  and 
kidneys  normal ;  pulse  rate,  72.  Patient  admitted  8  A.M.,  no  noon 


High  Blood-pressure  Usual,  101 

meal  was  allowed,  and  treatment  was  begun  in  afternoon  by 
administration  of 

Calomel gr.  iij. 

Podophyllin    gr.  %. 

Extract  rhubarb gr.  ij. 

Strychnine  nit gr.  %0. — One  capsule. 

A  capsule  containing  above  ingredients  was  given  at  4,  6,  8, 
and  10  P.M.  Patient  was  given  6  grains  of  morphine  at  10  A.M. 
and  the  same  quantity  at  3,  7,  and  10  P.M.,  the  10  P.M.  dose  being 
the  last  morphine  that  was  given  in  the  case. 

July  2d,  7  A.M.  Patient  had  a  good  night's  sleep  and  did  not 
wake  until  7  A.M.,  at  which  time  he  called  for  his  morning  dose  of 
morphine ;  this  was  not  allowed,  but  ^.5  grain  of  strychnine  was 
given  hypodermically,  followed  in  a  few  minutes  by  %  ounce 
Rochelle  salt.  Patient  was  nauseated  before  this  was  given  and 
the  salt  was  vomited.  Vomiting  was  attended  by  much  distress ; 
bowels  not  having  moved,  another  dose  of  salt  was  given  at  7.45 
and  electric  massage  of  bowels  used.  8.30.  Large  free  movement 
from  bowels  occurred,  nausea  ceased,  and  patient  became  much 
more  comfortable,  bowels  acted  again  at  9  and  9.45,  both  actions 
being  free.  Upon  returning  to  bed  after  the  third  action,  patient 
fell  asleep  and  slept  two  hours,  awaking  himself  at  12  M.  ;  this  was 
five  and  two  hours,  respectively,  after  the  usual  time  for  his 
morning  doses  of  morphine,  neither  of  which  had  been  given, 
but  at  12.30  he  said  he  had  gone  as  long  as  he  could  go  without  his 
morphine,  and  must  have  a  dose.  At  this  time  his  pulse  was  90, 
temperature  normal,  was  sneezing  and  yaw.ning  and  skin  was 
moist,  but  not  sweating  profusely. 

i  P.M.  Gave  %oo  grain  hyoscine  hypo. 

1.15  P.M.  Gave  %QO  grain  hyoscine  hypo. 

1.45  P.M.  Gave  %oo  grain  hyoscine  hypo. 

Soon  after  the  second  dose  patient's  skin  became  dry  and 
the  sneezing  stopped,  but  he  was  restless  and  uncomfortable. 
Half  an  hour  after  the  third  dose  was  given  patient's  face  was 


102  Narcotic  Drug  Diseases  and  Allied  Ailments. 

flushed  and  pupils  dilated;  complained  of  his  mouth  and  throat 
being  dry,  and  was  very  restless. 

2.45  P.M.  Patient  still  restless  and  suffering;  gave  %0o  grain 
hyoscine. 

3.45  P.M.  Patient  more  comfortable,  but  still  restless;  mind 
clear;  gave  }45  grain  hyoscine. 

4.45  P.M.  Patient  still  awake,  is  restless,  and,  while  he  says 
he  is  not  now  suffering  pain,  he  is  evidently  not  entirely  com- 
fortable; mind  is  beginning  to  wander  slightly;  gave  %5  grain 
hyoscine. 

5.30  P.M.  Patient  is  delirious,  talks  at  random,  picks  at 
cover,  and  tosses  about  on  bed ;  his  circulation  and  respiration  are 
practically  normal,  pupils  widely  dilated,  and  face  flushed. 

9  P.M.  Patient  has  been  more  quiet  for  the  last  two  hours; 
delirium  is  less  active  and  is  not  continuous;  patient  has  lucid 
moments  at  times,  and  says  he  has  pain  in  his  back ;  asked  for  a 
drink  of  water  and  drank  freely ;  passed  urine. 

9.30  P.M.  Gave  l/T5  grain  hyoscine. 

July  $d,  i  A.M.  Patient  was  very  restless  for  about  three- 
quarters  of  an  hour  after  the  9.30  dose  of  hyoscine ;  then  he  fell 
asleep  and  slept  an  hour;  soon  after  awaking,  delirium  became 
active  and  is  still  so ;  no  medicine. 

3  A.M.  Patient  has  been  quiet  during  last  hour,  delirium  has 
partially  subsided,  and  patient  says  he  has  pain  in  his  back ;  gave 
YIQO  grain  hyoscine. 

6  A.M.  Patient  was  restless  and  tossed  on  bed  for  about  half 
an  hour  after  the  last  dose  of  hyoscine,  but  has  not  been  so 
delirious;  says  now  that  his  legs  and  back  are  aching;  gave  %0o 
grain  hyoscine. 

9  A.M.  Half-hour  after  the  6  A.M.  dose  of  hyoscine  patient 
said  he  was  entirely  comfortable ;  drank  water  and  voided  urine ; 
mind  wandered,  but  was  not  actively  delirious. 

ii  A.M.  Says  he  is  uncomfortable  and  wants  morphine;  gave 
%5  grain  hyoscine. 


Case  Report  in  Detail.  103 

12  M.  Patient  restless  and  uncomfortable ;  gave  ^75  grain 
hyoscine. 

i  P.M.  Patient's  restlessness  was  continuous  for  half  an  hour 
after  noon  dose  of  hyoscine;  is  now  more  quiet,  but  is  delirious; 
lies  on  bed  and  picks  at  cover. 

6  P.M.  Patient's  condition  has  continued  as  above  until  during 
the  last  hour;  the  delirium  has  partially  subsided,  and  his  mind 
is  now  clear  at  times;  he  says  he  is  not  suffering  particularly, 
but  would  take  a  dose  of  morphine  if  he  had  it;  gave  %5  grain 
hyoscine. 

July  4th,  3  A.M.  Patient  was  restless  during  the  first  hour 
after  the  6  P.M.  dose  of  hyoscine  was  given,  during  which  time 
he  was  only  slightly  delirious,  but  in  about  an  hour  after  that 
dose  the  delirium  became  more  active  and  continued  so  for  three 
or  four  hours,  then  the  patient  fell  into  a  quiet,  semiconscious 
state,  and  that  has  continued  up  to  the  present  time.  Patient 
lies  quietly  in  bed,  and  has  taken  several  short  naps.  When  he 
is  sharply  aroused,  he  answers  questions  intelligently,  but  if  left 
to  himself  he  lapses  into  a  semiconscious  or  mildly  delirious 
condition. 

6  A.M.  Delirium  has  decreased  during  the  last  three  hours, 
and  patient's  mind  is  now  clear  most  of  the  time.     His  pulse  is 
now  60  per  minute,  this  being  30  per  minute  slower  than  at  the 
beginning  of  the  administration  of   hyoscine,   but   is  of   good 
quality.    Respiration  and  temperature  are  normal.     Patient  says 
he  is  free  from  pain,  but  feels  weak;  he  says  he  would  like  to 
have  something  to  strengthen  him,  but  does  not  want  morphine. 

6.10  A.M.  Gave  %0  grain  strychnine  and  %  ounce  of  Rochelle 
salt. 

7  A.M.  Patient  is  actively  delirious  again,  doubtless  due  to  the 
effects  of  strychnine  in  re-establishing  hyperemia  of  the  brain. 

i  P.M.  Active  delirium  continued  four  hours,  but  during  the 
last  two  hours  it  has  gradually  subsided  and  the  patient's  mind  is 
now  almost  clear;  two  movements  from  bowels  have  occurred 


104  Narcotic  Drug  Diseases  and  Allied  Ailments. 

during  the  last  hour;  stools  were  very  offensive  and  of  an  ex- 
tremely  dark  color;  patient  has  been   nauseated   and  has   just 
vomited  a  large  quantity  of  green  bilious  matter. 
2  P.M.  Small  liquid  bowel  movement. 

6  P.M.  Patient  fell  asleep  at  4  P.M.  and  has  just  awakened. 
His  mind  is  perfectly  clear,  and  he  says  he  is  comfortable  and 
has  no  desire  for  morphine,  but  would  like  to  have  something  to 
eat;  gave  glass  of  milk. 

7  P.M.  Vomited  milk  and  a  quantity  of  green  liquid. 

9  P.M.  Gave  20  grains  trional  and  tub  bath. 

July  5th,  7  A.M.  Patient  went  to  sleep  soon  after  coming  out 
of  bath  and  slept  one  and  one-half  hours;  then  was  awake  and 
restless  until  4  A.M.  ;  he  then  went  to  sleep  and  slept  an  hour  and 
a  quarter.  Has  been  awake  since  that  time.  He  says  he  is  not 
suffering  in  any  way,  but  feels  weak;  asked  for  cup  of  coffee. 
This  was  given  and  retained;  says  he  has  no  desire  for  food. 

7  P.M.  Patient  has  had  no  medicine  since  9  P.M.  last  night, 
at  which  time  20  grains  trional  were  given.  He  was  comfortable, 
took  light  nourishment  several  times  during  the  day,  but  took  it 
because  the  nurse  insisted  upon  his  doing  so,  rather  than  from  a 
desire  for  the  food;  during  the  afternoon  his  temperature  ran  up 
to  ioo%°  F.  and  he  has  complained  of  his  back,  limbs,  and  head 
aching;  is  now  very  uncomfortable  and  restless;  gave  %  grain 
pilocarpine  hypo. 

7.30  P.M.  Patient  in  profuse  perspiration  and  has  fallen  asleep. 

10  P.M.  Patient  slept  two  hours  and  ten  minutes  following  the 
dose  of  pilocarpine;  has  just  aroused  and  says  he  is  not  suffering. 
Temperature  98%°  F. 

10.30  P.M.  Gave  20  grains  trional. 

July  6th,  7  A.M.  Trional  did  not  seem  to  have  any  effect  on 
patient;  he  remained  awake  until  3  A.M.  and  then  went  to  sleep 
and  slept  two  and  one-half  hours.  On  awaking  says  he  is  com- 
fortable and  would  like  to  have  something  more  substantial  to 
eat.  This  was  given  and  he  ate  with  relish. 


Malarial    Complication.  105 

7  r.M.  Patient  ate  heartily  at  noon,  but  says  he  is  suffering 
too  much  to  eat  supper.  He  was  fairly  comfortable  during  the 
forenoon;  his  temperature  at  7  A.M.  was  98%°  F.,  at  noon  was 
99%°  F.,  and  is  now  ioo%°  F.  Pulse  90;  respiration  20.  He 
complains  of  aching  of  back,  limbs,  and  head.  Gave  10  grains 
phenacetin. 

9  P.M.  Patient  still  complaining;  temperature  100°  F.  Gave 
neutral  bath.  Kept  patient  in  tub  thirty  minutes,  by  the  end  of 
which  time  temperature  had  fallen  to  98%°  F. 

July  Jth,  7  A.M.  Patient  went  to  sleep  soon  after  completion 
of  bath  and  slept  three  hours,  but  has  been  awake  since  that 
time.  Says  he  is  not  particularly  uncomfortable,  but  does  not 
feel  sleepy.  Bowels  and  kidneys  have  acted  several  times  during 
the  night ;  discharges  from  bowels  are  offensive ;  patient  ate 
hearty  breakfast. 

2  P.M.  Patient  had  chill  at  I  P.M.,  and  temperature  is  now 
104°  F. ;  is  aching  all  over,  and  says  he  feels  as  if  his  head  will 
burst.  Gave  10  grains  phenacetin. 

4  P.M.  Gave  10  grains  phenacetin. 

6  P.M.  Temperature  is  now  100°,  and  patient  is  much  more 
comfortable.     Refilled  purgative  prescription  given  on  the   1st 
inst.,  except  that  the  strychnine  in  it  was  reduced  to  %o  grain  for 
each  dose  and  gave  capsule  at  6,  8,  10,  and  12  P.M.;  also  gave  40 
grains  quinine  bisulph.  by  inunction  in  glycerin  at  9  P.M. 

July  8th,  7  A.M.  Patient  perspired  freely  from  n  P.M.  to 
about  i  A.M.;  he  fell  asleep  at  12.30  and  slept  four  hours;  his 
temperature  is  normal  this  morning,  and  he  says  he  feels  com- 
fortable. Gave  %o  grain  strychnine  and  2  ounces  castor  oil ;  also 
repeated  quinine  inunction. 

12  M.  Bowels  have  acted  four  times  since  8  A.M.  ;  the  first  two 
discharges  were  large,  almost  black,  and  very  offensive ;  the  last 
three  were  smaller,  not  so  offensive,  and  show  fresh  bile. 

7  P.M.  Patient  missed  chill,  has  passed  a  comfortable  day; 
his  ears  ring  from  the  quinine,  but  otherwise  he  says  he  feels 


106  Narcotic  Drug  Diseases  and  Allied  Ailments. 

better  in  every  way  than  at  any  time  since  leaving  off  the  mor- 
phine. His  temperature  is  now  normal  and  has  not  been  above 
that  at  any  time  today.  He  was  very  hungry  during  the  after- 
noon and  has  just  eaten  a  hearty  supper. 

July  ^th,  7  A.M.  Patient  went  to  bed  at  9  P.M.  and  has  slept 
all  night;  said  he  felt  sleepy  at  9  P.M.  and  no  bath  or  sleeping 
powder  were  given.  On  awaking  this  morning  he  says  he  feels 
like  a  new  man,  and  he  certainly  looks  it.  His  skin  has  lost 
that  muddy  hue ;  his  eyes  are  bright  and  clear,  and  his  tongue  is 
clean  and  breath  free  from  offensive  odor. 

9  P.M.  Patient  has  spent  the  most  satisfactory  day  in  every 
way  that  he  has  had  since  the  beginning  of  treatment.  Tempera- 
ture has  remained  normal ;  no  medicine  has  been  given  up  to  this 
time,  but  20  grains  bisulphate  quinine  are  now  given  by  inunction. 
This  is  done  to  avoid  return  of  the  malarial  complication.  Has 
taken  three  full  meals  today,  but  no  medicine  except  the  quinine. 

July  loth,  8  A.M.  Patient  took  tub  bath  at  10  last  night  and 
was  asleep  within  half-hour  after  retiring  and  did  not  wake  until 
4  A.M.  He  then  remained  awake  about  an  hour,  and  then  slept 
from  5  to  6  A.M.,  making  a  total  of  six  and  one-half  hours'  sleep 
during  the  night.  Says  he  feels  better  this  morning  than  he  has 
for  many  years,  and  that  he  has  no  desire  whatever  for  morphine 
or  other  drugs;  says  he  doesn't  think  of  it  now  as  a  thing  that 
would  give  him  pleasure  or  increase  his  comfort;  he  says  he 
doesn't  want  anything  except  three  full  meals  today.  This  was 
allowed. 

July  nth,  8  A.M.  Patient's  condition  for  last  twenty-four 
hours  has  been  entirely  satisfactory ;  he  spent  most  of  day  yester- 
day on  lawn  and  in  afternoon  went  to  zoo,  accompanied  by  his 
nurse.  Upon  returning  he  said  he  felt  fatigued ;  his  temperature 
was  99%°  F.,  but  other  functions  were  normal;  ate  three  full 
meals,  but  took  no  medicine  until  9  P.M.,  at  which  time  5  grains 
quinine  were  given  by  mouth.  Neutral  bath  at  10  P.M.  was  fol- 
lowed by  good  night's  rest,  with  about  five  hours'  sleep.  Bowels 


Rapid  Gain  of  Flesh.  107 

and  kidneys  are  acting  normally,  and  patient  is  gaining  flesh 
rapidly. 

July  i4th,  8  A.M.  No  change  in  patient's  condition  during  the 
last  three  days,  except  rapid  increase  in  flesh  and  strength.  The 
only  medicine  given  was  a  5-grain  capsule  of  quinine  each  night 
until  last  night,  at  which  time  30  grains  of  bisulphate  were  used 
by  inunction.  This  being  the  seventh  day  from  the  time  on  which 
the  malarial  chill  occurred,  it  was  thought  best  to  fully  cinchonize 
the  patient  and  thereby  more  certainly  prevent  a  return  of  the 
malarial  paroxysm.  Patient's  appetite  is  good,  and  he  is  sleeping 
five  or  more  hours  each  night. 

July  sist,  8  A.M.  Patient  missed  chill  on  the  I4th  and  has 
shown  no  malarial  symptoms  since.  Quinine  was  omitted  until 
last  night,  at  which  time  30  grains  bisulphate  dissolved  in  2  drams 
warm  glycerin  were  used  by  inunction.  This  being  the  four- 
teenth day  from  the  time  of  malarial  paroxysm,  another  would 
likely  occur  today  unless  prevented  by  quinine. 

9  P.M.  Patient  passed  time  for  chill  without  any  symptom  of 
malaria ;  his  ears  have  been  ringing  from  the  quinine,  but  other- 
wise has  spent  comfortable  day.  Is  eating  heartily  and  sleeping 
from  four  to  six  hours  each  night. 

July  28th,  8  A.M.  Patient  has  not  taken  a  dose  of  medicine 
of  any  kind  during  the  last  week  until  last  night;  today  being 
twenty-first  day  from  the  day  upon  which  the  malarial  chill 
occurred,  or  the  third  period  at  which  a  return  of  malarial 
paroxysm  would  likely  occur,  30  grains  quinine  were  given  by 
inunction  at  9  P.M.  last  evening.  Patient  lost  weight  during  the 
first  week  of  treatment,  but  has  gained  rapidly  since  that  time. 
He  now  weighs  160  pounds,  being  a  net  gain  of  20  pounds  since 
beginning  treatment.  Has  gained  more  than  a  pound  a  day  dur- 
ing the  last  two  weeks.  He  is  still  eating  heartily,  but  digestion 
is  not  so  good  during  the  last  week  as  it  was  before  that  time; 
complains  of  fullness  of  the  stomach  after  eating  and  bowels  act 
too  often ;  in  fact,  he  has  a  fermentative  diarrhea,  does  not  sleep 
as  well  as  during  preceding  week. 


108  Narcotic  Drug  Diseases  and  Allied  Ailments. 

A  fast  of  twenty-four  hours,  to  be  followed  by  active 
cathartic,  was  ordered. 

July  30th.  Patient's  fast  and  purgative  have  overcome  all  dis- 
comfort about  stomach ;  also  corrected  the  diarrhea. 

August  5th.  Thirty  grains  quinine  by  inunction  given  at  9  P.M. 
to  complete  cure  of  malarial  complication.  No  other  medicine. 

August  i2th.  Patient  has  had  no  medicine  during  the  last  four 
weeks,  except  quinine  for  his  malaria  and  a  purgative  to  correct 
bowel  disorder.  He  has  continued  to  gain  flesh  and  now  weighs 
175  pounds,  a  net  gain  of  45  pounds  since  he  began  treatment  six 
weeks  ago.  He  now  looks  the  picture  of  health,  but  he  has  not 
gained  strength  as  rapidly  as  he  has  gained  flesh ;  however,  as  he 
intends  to  spend  a  couple  of  months  in  the  country  fishing  and 
hunting,  he  is  this  day  discharged  from  the  sanitarium. 

February  4,  1904.  Patient  in  passing  through  the  city  called 
at  sanitarium  today.  It  has  been  a  little  over  six  months  since 
he  entered  for  treatment.  He  now  weighs  190  pounds  and  is  in 
perfect  health.  He  says  he  remained  in  country  and  took  much 
out-of-door  exercise  for  over  two  months  after  leaving  the 
sanitarium,  but  has  been  actively  engaged  in  his  business  during 
the  last  three  months;  says  he  has  not  at  any  time  had  the 
slightest  desire  for  morphine  or  any  other  drugs.  He  says  he 
feels  normal  in  every  way  and  enjoys  life  more  than  he  ever  did. 
He  says  his  years  of  slavery  and  suffering  gave  him  a  far  greater 
appreciation  of  freedom  and  health  than  he  had  before  he  fell 
a  victim  to  morphine.  He  is  now,  unquestionably,  a  very  happy 
man. 

CASE  VI. — Mrs.  R.  A.  Admitted  January  21,  1912.  Aged 
40 ;  weight,  135 ;  height,  five  feet  six  inches.  Family  history  good ; 
mother  of  several  children.  Use  of  morphine  begun  ten  years  ago 
for  relief  of  pain,  it  being  first  administered  by  a  physician.  The 
use  has  been  continuous  from  that  time  till  now.  During  the  last 
two  or  three  years  from  12  to  20  grains  have  been  taken  daily 


High  Arterial  Tension.  109 

by  mouth.  This  was  usually  divided  into  three  doses,  and  these 
were  taken  a  short  time  before  each  meal ;  none  was  taken  during 
the  night. 

The  following  clinical  notes  give  the  treatment  of  this  case 
in  detail : — 

January  22d,  8  A.M.  4  grains  morphine  by  mouth. 

9  A.M.  Breakfast. 

ii  A.M.  Physical  examination.  Temperature,  98%°;  pulse, 
84;  blood-pressure,  systolic  180,  diastolic  130;  pulse-pressure,  50. 
Tracing  No.  I  taken. 


Tracing  No.  I. 

12  M.  4  grains  morphine  by  mouth  (no  dinner). 

4  P.M.   Tablet   containing   calomel,   2^2    grains;   powd.    ext. 
cascara,  2^  grains;  ipecac,  V^  grain;  strychnine  nit.,  %0  grain; 
atropine  sulphate,  ^Oo  grain,  given  by  mouth  and  repeated  at  6, 
8,  and  10  P.M. 

5  P.M.  4  grains  morphine  by  mouth.    No  supper  was  allowed. 
Patient  retired  at  10.30  and  slept  till  5  A.M. 

January  2$d,  5  A.M.  Gave  %o  grain  strychnine  hypo. 
5.30  A.M.  Gave  %  ounce  Rochelle  salt. 

6  A.M.  Large  movement  from  bowel. 
7.30  A.M.  Liquid  bowel  movement. 

8  A.M.  Bowel  movement.     No  discomfort  attended  or  pre- 
ceded bowel  movements. 

9  A.M.  Says  she  feels  the  need  of  a  dose  of  her  drug. 
9.10  A.M.  Gave  2  grains  morphine  hypodermically. 

12  M.  Pulse,  84;  temperature,  98%°  ;  blood-pressure,  systolic 
170,  diastolic  125 ;  pulse-pressure,  45. 


110  Narcotic  Drug  Diseases  and  Allied  Ailments. 

12.30  P.M.  Gave  2  grains  morphine  hypodermically.  This 
served  to  carry  the  patient  in  comfort  to  the  time  of  her  evening 
dose,  which  was  given  at  6  P.M.  Two  grains  were  then  given 
hypodermically.  She  was  allowed  light  dinner  and  full  supper, 
which  was  taken  with  relish. 

January  24th,  8  A.M.  Patient  slept  well  all  night,  is  hungry. 
Full  breakfast  allowed  after  giving  2  grains  morphine  hypo. 
Patient  is  menstruating,  has  menstruated  occasionally,  notwith- 
standing her  use  of  the  opiate.  This  flow  lasted  during  the  24th, 
25th,  and  26th,  during  which  days  no  medicine  was  given,  except 
to  continue  the  morphine  in  2-grain  doses,  hypo.,  three  times  a 
day.  These  fully  satisfied  her,  and  she  said  she  felt  more  com- 
fortable than  when  taking  it  by  mouth.  The  fact  that  her  dose 
had  been  so  greatly  reduced  was  not  made  known  to  her. 

January  2?th.  Menstrual  flow  having  ceased,  treatment  was 
resumed.  Breakfast  was  allowed  on  this  day,  but  no  dinner  or 
supper.  Two  grains  morphine  at  7.30,  11.30  A.M.,  and  6  P.M. 
The  6  P.M.  dose  of  morphine  was  the  last  opiate  given  in  the  case. 
Purgative  course  same  as  above  was  begun  at  4  P.M.,  and  tablet 
of  size  and  strength  above  noted  was  given  at  4,  6,  8,  and  10  P.M., 
with  tub  bath  at  8  P.M. 

January  28th.  Patient  slept  from  n  P.M.  to  5  A.M. 

5.30  A.M.  Gave  %0  grain  strychnine  hypo.,  followed  at  6  A.M. 
by  %  ounce  Rochelle  salt. 

6.10  A.M.  Large  free  bowel  movement.  No  nausea  or  other 
distress. 

6.30  A.M.  Large  bowel  movement. 

7.30  A.M.  Free  watery  bowel  movement. 

9  A.M.  Watery  bowel  movement. 

9.30  A.M.  Patient  fell  asleep  and  slept  till  n  A.M. 

ii  A.M.  Patient  has  just  aroused  from  sleep.  Examination  at 
this  time  showed  temperature,  98%°;  pulse,  90;  respiration,  24, 
and  blood-pressure,  systolic  140,  diastolic  no;  pulse-pressure,  30, 


Arterial  Tension  Reduced  by  Treatment.  Ill 

this  being  a  reduction  of  40  mm.  in  systolic  pressure  from  record 
at  time  of  beginning  treatment.  Tracing  No.  2  taken. 

11.15  A-M-  Says  she  is  beginning  to  feel  the  need  of  morphine, 
but,  instead  of  giving  that,  gave  %0o  grain  scopolamine  hypo. 

11.45  A-M-  Gave  %oo  grain  scopolamine  hypo. 

12.15  P-M-  Pulse,  90;  respiration,  28;  temperature,  98%°; 
blood-pressure,  systolic  145.  Patient  resting  quietly  and  is 
drowsy. 

12.45  P.M.  Gave  %oo  grain  scopolamine. 

1.45  P.M.  Temperature,  98%°;  pulse,  100;  respiration,  28; 
blood-pressure,  systolic  130.  Patient  is  quiet  and  sleepy. 


Tracing  No.  2. 

3  P.M.  Gave  %0o  grain  scopolamine.  Patient  had  small  bowel 
movement,  and  a  few  minutes  after  getting  back  in  bed  fell  asleep 
and  slept  one  and  one-half  hours. 

4.50  P.M.  Voided  4  ounces  of  urine.     Drank  glass  of  water. 

5.40  P.M.  Gave  %oo  grain  scopolamine;  pulse,  100;  respira- 
tion, 26;  blood-pressure,  145. 

8  P.M.  Gave  %0o  grain  scopolamine. 

9  P.M.  Gave  %0o  grain  scopolamine.     Patient  says  she  is 
comfortable.     Mind  is  perfectly  clear. 

II  P.M.  Patient  fell  asleep  soon  after  9  P.M.,  and  has  just 
aroused  from  sleep.  Says  she  is  not  suffering,  answers  questions 
intelligently,  but  when  left  to  herself  her  mind  wanders  slightly. 
Is  quiet  and  comfortable.  This  condition  continued  until  2.30 
A.M.,  at  which  time  her  mind  was  practically  clear  and  she  said 
she  was  beginning  to  feel  uncomfortable. 

3  A.M.  Gave  %0o  grain  scopolamine.  Pulse,  100;  respiration, 
26;  blood-pressure,  135.  Patient  voided  urine  and  drank  glass 
of  water. 


112  Narcotic  Drug  Diseases  and  Allied  Ailments. 

4  A.M.  Gave  %0o  grain  scopolamine. 

7  A.M.  Gave  %0o  grain  scopolamine. 

9  A.M.  Patient  was  restless  from  7  to  7.30,  but  has  been  quiet 
since  that  time.  Is  semiconscious.  Temperature,  98%° ;  pulse, 
88;  respiration,  19;  blood-pressure,  systolic  140,  diastolic  no; 
pulse-pressure,  30.  Pulse  tracing  No.  3  taken. 

January  2$>th,  n  A.M.  Gave  %oo  grain  scopolamine.  Voided 
urine. 

2.30  P.M.  Gave  %oo  grain  scopolamine. 

9  P.M.  Patient  was  restless  from  2.30  to  3  P.M.,  but  has  been 
quiet  since  that  time.  Mind  wanders  and  has  been  slightly 


Tracing  No.  3. 

delirious,  but  when  spoken  to  answers  intelligently.     Asked  to 
be  taken  to  toilet  to  void  urine  and  drank  water  several  times. 

9.10  P.M.  Gave  %  grain  podophyllin,  2%  grains  ext.  cascara, 
%  grain  ipecac,  %0  grain  strychnine,  %0o  grain  atropine  by 
mouth,  and  a  dose  of  this  size  was  again  given  at  n  P.M.  and 

I  A.M. 

January  30th,  6.30  A.M.  Patient  fell  asleep  at  3,  and  slept  till 
6  A.M.  On  waking,  says  she  feels  comfortable,  but  her  mind  is 
not  entirely  clear. 

6.35  A.M.  Gave  %5  grain  gelseminine  hypo. 

7  A.M.  Dark  bilious  bowel  movement. 

8  A.M.  Says  she  is  hungry.     Gave  milk  toast. 

9  A.M.  Gave  orange  juice. 

9.30  A.M.  Mind  perfectly  clear.     Gave  general  bath, 
ii  A.M.  Pulse,  80;  respiration,  16;  temperature,  98%°  ;  blood- 
pressure,  systolic  140.     Pulse  tracing  No.  4  taken. 


Heart  Action  Sustained   by   Treatment.  113 

It  is  now  forty-eight  hours  from  time  of  beginning  the  ad- 
ministration of  scopolamine.  All  symptoms  of  delirium  sub- 
sided between  7  and  9  A.M.  Mind  is  now  clear,  and  she  says  she 
is  entirely  comfortable,  and  that  she  has  no  desire  for  morphine, 
but  that  she  wants  something  to  eat.  Liquid  nourishment  allowed. 

11.30  A.M.  Free  bilious  bowel  movement.     Voided  urine. 

12.45  P-M-  Patient  fell  asleep  soon  after  returning  to  bed  after 
bowel  movement  and  slept  an  hour.  Took  soup  and  buttermilk 
with  relish. 

2.30  P.M.  Lemonade  given. 

4  P.M.  Patient  slept  from  3  to  4  P.M. 


Tracing  No.  4. 

4.10  P.M.  Small  bilious  bowel  movement. 

6  P.M.  Temperature,  99°;  respiration,  18;  pulse,  80.  Patient 
slept  from  5  to  6  P.M. 

6.30  P.M.  Buttermilk  and  toast.    Quiet  and  comfortable. 

9.30  P.M.  Gave  10  grains  sulphonal. 

January  jist,  6  A.M.  Patient  passed  a  good  night.  Went  to 
sleep  at  1.30  A.M.,  and  slept  until  5.30.  On  waking,  says  she  feels 
weak,  but  has  no  desire  for  morphine  or  any  other  drug.  Wants 
something  to  eat.  Hot  milk  toast  and  an  orange  given. 

8  A.M.  Temperature,  99°;  pulse,  92;  respiration,  18;  blood- 
pressure,  systolic  140,  diastolic  115;  pulse-pressure,  25;  urine 
scanty.  Gave  2  grains  sparteine  by  hypo. 

10  A.M.  Tub  bath,  following  which  the  patient  slept  an  hour 
and  a  half.  On  waking,  says  she  feels  well.  Buttermilk  and 
toast  taken  with  relish. 

i  P.M.  Gave  5  minims  hydrochloric  acid  in  fourth  of  a  glass 
of  water,  followed  by  a  light  dinner. 


114           Narcotic  Drug  Diseases  and  Allied  Ailments. 

6.30  P.M.  Hydrochloric  acid  and  supper.  Spent  comfortable 
afternoon. 

10  P.M.  Neutral  bath.     No  medicine. 

February  ist,  8  A.M.  Patient  went  to  sleep  about  half-hour 
after  completion  of  the  bath  and  slept  most  of  the  night  without 
medicine  of  any  kind.  Is  quiet  and  comfortable  and  says  she  is 
hungry.  Full  breakfast  allowed,  preceded  by  dose  of  hydro- 
chloric acid.  No  other  medicine. 

11  A.M.  Temperature,  99°;  pulse,  88;  respiration,  18;  blood- 
pressure,  systolic  155,  diastolic  120;  pulse-pressure,  35.    Tracing 
No.  5  taken.     Bowel  and  kidneys  acting  normally. 


Tracing  No.  5. 

8  P.M.  Patient  has  spent  the  day  in  comfort.  Was  given  light 
dinner  and  supper;  the  only  medicine  given  was  the  acid  before 
each  meal. 

10  P.M.  General  massage  and  neutral  bath. 

February  2d,  8  A.M.  Patient  slept  from  10.30  to  I  A.M.,  and 
from  3  to  6  A.M.,  making  five  and  one-half  hours  for  the  night. 
Is  up  and  dressed  and  was  allowed  to  go  to  dining  room  for 
breakfast.  Says  she  feels  much  stronger  and  will  spend  the 
morning  in  writing  letter  to  her  family. 

11  A.M.  Temperature,  99°;  pulse,  90;  respiration,  20;  blood- 
pressure,  155.    No  medicine  today,  except  acid  before  meals. 

8  P.M.  Temperature,  99%° ;  pulse,  95;  respiration,  22;  blood- 
pressure,  155.  Patient  has  taken  three  full  meals  today.  Is  not 
so  comfortable  as  on  yesterday.  Gave  10  grains  aspirin  to  reduce 
temperature. 


Pulse   Tracings  During   Treatment.  115 

10  P.M.  Neutral  bath.  The  aspirin  given  at  8  P.M.  reduced 
the  temperature  to  99°.  The  bath  completed  the  reduction  to 
normal. 

February  $d,  8  P.M.  Patient  spent  a  comfortable  night.  Slept 
four  hours  after  the  bath  and  was  awake  then  for  couple  of 
hours ;  slept  again  from  5  to  6  A.M.  Patient  put  on  a  more  re- 
stricted diet.  No  medicine  today  except  hydrochloric  acid  before 
meals. 

8  A.M.  Temperature,  99%°  ;  pulse,  88;  respiration,  20;  blood- 
pressure,  systolic  150.  Bowels  and  kidneys  acting  normally. 
Has  been  more  comfortable  than  on  yesterday.  Temperature 
reached  99%°  at  I  P.M.,  and  remained  stationary  at  that  degree 
to  8  P.M.  Gave  10  grains  aspirin,  massage,  and  neutral  bath  at 
10  P.M. 

February  4th,  8  A.M.  Patient  slept  two  and  one-half  hours 
after  the  bath,  but  on  waking  did  not  go  back  to  sleep.  Became 
restless  and  uncomfortable.  Temperature  was  found  to  be  99%°. 
Gave  %  grain  pilocarpine  at  3  A.M.  This  was  followed  by  free 
diaphoresis.  Patient  fell  asleep  at  3.30  and  slept  till  6  A.M. 

February  8th,  8  A.M.  The  condition  of  the  patient  for  the 
last  three  days  has  been  practically  the  same  as  recorded  on  the 
3d  and  4th.  The  pulse  rate  has  been  from  85  to  95 ;  respiration 
from  18  to  22;  blood-pressure,  systolic  150  to  155,  diastolic  115 
to  120;  pulse-pressure,  30  to  35.  Temperature  usually  99°  in  the 
morning,  running  up  to  99%°  to  99%°  by  I  P.M.,  remaining  at 
this  point  during  the  afternoon  and  evening  unless  reduced  by 
aspirin,  pilocarpine,  or  a  neutral  bath  or  wet  pack.  When  the 
temperature  was  not  above  99°  the  patient  was  comfortable,  but 
as  the  temperature  rose  even  to  three-  or  four-  fifths  of  a  degree 
above  that  she  was  conscious  of  it  and  was  not  so  comfortable. 

One  or  two  doses  of  aspirin  were  given  each  afternoon. 
These  served  to  reduce  the  temperature  and  make  the  patient 
quite  comfortable.  The  neutral  bath  was  used  at  bedtime  as  an 
hypnotic,  as  well  as  for  its  antipyretic  effect.  Patient  slept  from 


116  Narcotic  Drug  Diseases  and  Allied  Ailments. 

four  to  six  hours  each  night  and  expressed  herself  as  being  most 
grateful  for  the  release  from  drug  slavery.  Appetite  has  been 
rather  too  good,  and  it  has  been  difficult  to  keep  her  from  over- 
taxing her  digestive  organs;  in  fact,  success  has  not  been  at- 
tained in  that  effort,  and  it  is  evident  that  she  is  suffering  from 
an  acute  intestinal  toxemia.  Bowels  are  loose  and  stools  show 
fermentation.  A  fast  of  a  day  ordered. 

February  8th,  3  P.M.  The  stomach  being  now  empty,  a  purga- 
tive course,  consisting  of  calomel  10  grains,  ext.  cascara  10  grains, 
ipecac  I  grain,  strychnine  nit.  %  grain,  and  atropine  %0  grain, 
divided  into  four  potions,  was  prepared  and  a  pction  given  at 
3,  5,  7,  and  9  P.M.  Fast  continued. 

February  9th,  6  A.M.  %0  grain  strychnine  given  hypoder- 
mically. 

6.30  A.M.  Bottle  citrate  magnesia. 

7  A.M.  Free  bowel  movement,  and  this  was  followed  by  three 
additional  movements  between  7  A.M.  and  noon. 

i  P.M.  Temperature,  98%°;  pulse,  85;  respiration,  18;  blood- 
pressure,  systolic  140,  diastolic  no;  pulse-pressure,  30.  JTempera- 
ture  showed  no  change  from  the  normal  until  5  P.M.,  when  it  was 
98%°.  An  aspirin  capsule  reduced  it  to  normal.  Patient  has 
been  quiet  and  entirely  free  from  discomfort  all  day.  Was 
allowed  liquid  nourishment  at  noon  and  light  supper. 

February  I2th.  Patient  has  spent  the  last  three  days  in  most 
satisfactory  condition.  Was  much  relieved  by  the  action  of  the 
purgative  given  on  the  8th  instant.  Has  taken  nourishment 
freely,  but  appetite  has  not  been  so  ravenous  since  that  time. 
Has  slept  from  five  to  six  hours  out  of  each  twenty-four,  has 
spent  most  of  each  afternoon  outdoors,  she  and  her  nurse  at- 
tending matinees,  visiting  parks,  etc.  Temperature  has  not  gone 
above  99°  at  any  time  since  the  action  of  the  purgative  given  on 
the  8th  instant.  Patient  has  been  entirely  comfortable  during 
these  days  and  is  gaining  flesh  and  strength  rapidly.  At  n  A.M. 
today  pulse  is  85;  temperature,  98%°;  respiration,  18;  blood- 
pressure,  140.  Bowels  and  kidneys  are  acting  normally. 


Condition  During  Convalescence.  117 

February  i8th.  Patient's  improvement  has  continued  without 
interruption.  No  medicine  has  been  given  during  the  last  week. 
Temperature  has  been  normal  most  of  the  time,  except  late  in 
afternoon,  when  a  rise  of  two-  or  three-  fifths  of  a  degree  has 
been  noted.  A  neutral  bath  at  bedtime  has  been  sufficient  to  re- 
duce this  and  procure  good  night's  sleep.  Appetite  is  good,  but 
has  been  kept  on  a  somewhat  restricted  diet. 

February  2jth.  It  has  been  a  month  today  since  the  last  dose 
of  morphine  was  given.  Patient  now  looks  to  be  in  perfect 
health,  but  when  she  attempts  to  do  anything  she  finds  that  her 
strength  is  not  sufficient  to  sustain  her  without  feeling  fatigue. 
Her  present  weight  is  150  pounds,  being  a  gain  of  15  pounds 
since  beginning  treatment.  Pulse,  respiration,  and  temperature 
are  now  practically  normal.  Observations  made  at  n  A.M.  daily 
have  shown  an  average  blood-pressure  of  140,  this  being  a  main- 
tained reduction  of  40  mm.  Hg  from  height  of  pressure  when 
taking  morphine.  Patient  says  she  can  hardly  realize  that  she 
was  a  slave  to  morphine  and  never  thinks  of  it  now  as  a  thing  that 
would  give  her  pleasure.  Patient  put  on  a  course  of  physical 
training,  with  restricted  diet,  but  no  medicine. 

March  ifth.  Patient  has  gained  in  strength  rapidly  during  the 
last  two  weeks,  due  largely  to  the  systematic  exercise  involved  in 
the  course  of  physical  training.  Has  only  gained  5  pounds  in 
flesh,  and  is  now  up  to  her  full  standard  of  weight  when  in 
health.  Her  bowels  and  kidneys  are  acting  normally,  appetite 
is  good,  and  she  is  sleeping  six  hours  or  more  each  night  without 
medicine  of  any  kind.  Not  a  dose  of  medicine  has  been  given 
her  during  the  last  three  weeks.  Patient  is  now  considered  in 
safe  condition  to  be  discharged  and  she  was  sent  home  today. 

AUTHOR'S  COMMENT. 

By  reference  to  the  clinical  notes  it  will  be  seen  that 
this  patient  was  almost  entirely  free  from  discomfort 
during  the  first  five  days  after  the  completion  of  the 


118  Narcotic  Drug  Diseases  and  Allied  Ailments. 

active  treatment  period.  During  those  days  her  meals 
were  served  in  her  room  and  she  was  kept  on  light  and 
restricted  diet,  then  she  was  allowed  to  go  to  the  dining 
room  and  eat  a  liberal  diet. 

A  few  days  of  this  liberal  diet  brought  an  increase  in 
pulse  rate,  temperature,  and  blood-pressure,  accompanied 
by  the  discomfort  incident  to  acute  intestinal  toxemia. 
This  discomfort  was  allowed  to  continue  a  few  days, 
during  which  time  no  restriction  was  placed  on  the 
patient's  diet  and  the  discomfort  of  the  patient  increased 
each  day.  This  course  was  pursued  and  this  toxic  con- 
dition was  allowed  to  develop  for  the  purpose  of  impress- 
ing a  lesson  which  is  essential  to  the  safety  from  relapse 
of  every  drug  patient. 

Had  this  patient  been  left  to  herself,  or  had  she  ap- 
plied to  a  physician  for  relief  from  these  symptoms,  some 
palliative  would  almost  certainly  have  been  resorted  to 
that  would  have  made  bad  matters  worse. 

After  having  permitted  her  to  experience  the  dis- 
comfort due  to  acute  intestinal  toxemia  the  cause  of  her 
discomfort  was  explained  to  her,  a  fast  enjoined,  and 
this  was  followed  by  a  physiologically  balanced  purgative 
course.  The  action  of  this  purgative  removed  the  cause 
of  her  discomfort  and  gave  complete  relief  and  not 
another  unpleasant  symptom  developed  in  the  case. 

Acute  intestinal  toxemia  developed  earlier  in  this 
case  than  is  usual.  It  could  have  been  delayed  longer 
by  keeping  her  on  a  more  restricted  diet.  The  average 
patient  if  left  to  eat  to  satisfy  the  appetite,  as  they  are 
disposed  to  do,  usually  develops  acute  digestive  disturb- 
ances about  the  end  of  the  second  week  after  withdrawal 
of  the  drug.  This  can  be  put  off  to  a  later  period  by 
strict  diet,  but  it  can  hardly  be  avoided  altogether,  and 
the  author  does  not  believe  that  it  is  best  to  try  to  avoid 


Intestinal  Toxemia,  Discomfort  from.  119 

it  until  the  patient  has  been  taught  the  lesson  which  it 
involves. 

The  stomach  is  no  stronger  than  the  balance  of  the 
body.  During  the  first  few  weeks  after  being  taken  off 
of  a  drug,  if  the  patient  was  called  upon  to  do  a  full 
day's  work,  he  would  be  quite  unequal  to  it ;  yet  if  left 
to  follow  his  own  bent  in  the  matter,  he  will  eat  so  freely 
as  to  put  a  full  day's  work  on  his  stomach  each  day. 

The  digestive  organs  may  do  this  work  for  a  short 
time,  but,  being  overtaxed  day  by  day,  they  must  neces- 
sarily show  the  effect  of  such  overwork  and  then  acute 
digestive  disturbances  arise,  but  before  these  are  marked 
enough  for  the  patient  himself  to  recognize  them,  or  for 
a  physician  without  experience  in  such  cases  to  diagnose 
them,  there  will  have  been  days  and  probably  weeks  of 
discomfort.  This  discomfort  strongly  suggests  to  the 
patient  the  need  of  his  former  drug  and  often  leads  to 
relapse. 

The  patient  is  certain  to  interpret  this  discomfort  as 
being  due  to  abstinence  from  his  drug,  and  if  the  advice 
of  a  physician  is  asked  he  is  more  than  likely  to  say  that 
such  discomfort  is  to  be  expected  to  follow  the  with- 
drawal of  an  opiate,  etc. 

With  both  the  physician  and  the  patient  connecting 
the  suffering  with  the  former  drug  addiction,  the  chances 
are  that  each  of  them  will  reach  the  conclusion  that, 
since  the  suffering  is  such  as  to  demand  relief,  an  opiate 
is  the  only  remedy  which  can  be  expected  to  give  that 
relief,  and  this  leads  to  ruin. 

As  a  matter  of  fact  the  suffering  has  no  connection 
with  the  former  drug  addiction,  except  that  the  anemic 
condition  incident  to  the  use  of  the  narcotic  so  impaired 
the  activity  of  the  digestive  organs  that  they  were  unable 
to  stand  the  tax  placed  upon  them,  and,  as  a  result  of 
this,  deranged  metabolism  resulted  in  acute  toxemia. 


120           Narcotic  Drug  Diseases  and  Allied  Ailments. 

The  condition  should  be  recognized  and  attributed 
to  its  real  cause,  and  not  held  to  be  a  necessary  sequel  of 
drug  addiction. 

The  treatment  is  rest  for  the  overtaxed  organs  by 
two  or  more  days'  fasting,  during  which  eliminants 
sufficient  to  fully  cleanse  the  system  from  toxic  matter 
are  to  be  given.  Under  this  course  these  symptoms  dis- 
appear like  magic,  and  the  patient  is  ever  afterward  a 
wiser  man  and  more  ready  to  observe  dietary  regulations. 

The  author  thinks  it  is  best  to  allow  every  patient 
to  overtax  his  digestive  organs  while  in  the  institution 
and  pass  through  this  experience,  as  only  by  that  means 
can  the  lesson  be  sufficiently  impressed. 

If  he  is  kept  on  restricted  diet  while  at  the  institution 
and  thereby  toxic  conditions  are  avoided,  he  is  sure  to 
overtax  his  digestive  organs  as  soon  as  he  is  thrown  on 
his  own  resources  and  then  he  will  begin  to  suffer,  and 
suffering  at  such  a  time  is  dangerous. 

Such  suffering  reminds  the  patient  of  the  sense  of 
relief  he  formerly  obtained  from  doses  of  his  drug,  and 
this  is  an  oft-recurring  autosuggestion  to  resort  to  it 
again.  Therefore,  every  patient  should  be  taught,  in  the 
most  impressive  manner  possible,  the  nature  of  these 
toxic  states,  how  to  avoid  them,  the  symptoms  indicating 
their  presence,  and  how  to  treat  them  when  they  do 
occur.  Such  instruction  fortifies  him  against  relapse  to 
a  greater  degree  than  almost  anything  else  that  can  be 
done  for  him. 

CASE  VII. — J.  H.  H.,  male,  aged  30,  height  5  feet  8  inches, 
weight  150  pounds,  admitted  February  12,  1912. 

History. — Began  the  use  of  morphine  for  relief  of  chronic 
dysentery  six  years  ago.  Bowel  trouble  disappeared  about  four 
months  after  beginning  the  use  of  morphine,  but  was  then  unable 
to  give  up  the  use  of  the  drug,  and  it  has  been  used  hypodermi- 


Daturine,   Case   Treated    With.  121 

cally  from  that  time  until  now,  the  daily  dose  gradually  increas- 
ing until  the  quantity  taken  now  is  30  grains  per  day.  This  is 
taken  at  four  doses,  one  about  7  A.M.,  one  at  noon,  one  at  5  to  6 
P.M.,  and  one  at  bedtime,  about  10  P.M.  Has  lost  30  pounds  in 
weight,  i.e.,  much  more  than  that  was  lost  during  the  attack  of 
dysentery.  After  that  subsided,  weight  increased  to  160  pounds, 
but  did  not  go  up  to  180,  which  was  his  weight  when  in  health. 
During  the  last  two  years  weight  has  run  down  slightly  and  is 
now  150,  this  being  30  pounds  below  his  standard  weight  when 
in  health. 

Physical  Examination. — Heart  and  lungs  normal.     Kidneys 
acting  normally,  but  urine  is  heavily  loaded  with  indican.    Bowels 


Tracing  No.  6. 

habitually  constipated;  tongue  furred;  breath  foul;  pulse,  80; 
respiration,  16;  blood-pressure,  systolic  175,  diastolic  120;  pulse- 
pressure,  55.  Pulse  tracing  No.  6  taken. 

February  ijth.  Began  treatment  by  abstinence  from  dinner 
and  at  3,  5,  7,  and  9  P.M.  a  purgative  capsule  made  according  to 
the  formula  given  in  the  preceding  case  was  given.  7^  grains 
of  morphine  were  given  at  5  P.M.  and  at  9.30  P.M.  No  supper. 

February  i^th,  6  A.M.  Gave  %o  grain  strychnine  hypodermi- 
cally. 

6.30  A.M.  Gave  bottle  citrate  magnesia. 

7.30  A.M.  Bowels  moved  very  freely.  No  nausea  or  other 
discomfort  accompanied  the  movement. 

8  A.M.  Another  large  bowel  movement,  after  which  patient 
fell  asleep  and  slept  until  10  A.M. 

10.30  A.M.  Free  watery  bowel  movement.  Patient  quiet  and 
comfortable.  Is  drowsy. 


122           Narcotic  Drug  Diseases  and  Allied  Ailments. 

12  M.  Patient  says  he  has  not  missed  the  morning  dose  of 
morphine,  but  is  now  beginning  to  feel  nervous  and  uncomfort- 
able and  wants  a  dose.  At  this  time  3  grains  of  morphine  were 
given  hypodermically  and  patient  given  light  meal. 

5  P.M.  Patient  has  spent  a  comfortable  afternoon.  It  is  now 
time  for  his  evening  dose.  3  grains  morphine  given  and  full 
supper  allowed,  which  was  taken  with  relish. 

10  P.M.  Gave  3  grains  morphine. 

February  itfh,  7  A.M.  Patient  slept  all  night.  On  waking,  his 
pulse  is  70;  respiration,  18;  blood-pressure,  systolic  150,  diastolic 
no;  pulse-pressure,  40.  Gave  3  grains  morphine  and  allowed 
full  breakfast. 

8.30  A.M.  Pulse,  80;  respiration,  16;  blood-pressure,  systolic 
1 60. 

12  M.  Gave  3  grains  morphine.    No  dinner. 

4  P.M.  Gave  purgative  capsule  same  as  above  noted  and  re- 
peated same  at  6,  8,  and  10  P.M.    No  supper. 

5  P.M.  and  at  10  P.M.  Gave  3  grains  morphine,  the  10  P.M. 
dose  being  the  last  morphine  given  in  the  case. 

February  i6th,  6  A.M.  Gave  %0  grain  strychnine  hypo.,  fol- 
lowed at  6.30  A.M.  by  2  ounces  castor  oil. 
7  A.M.  Free  bowel  movement. 
7.45  A.M.  Free  bowel  movement. 

9  A.M.  Patient  has  been  asleep  for  the  last  hour.    On  waking, 
bowels  moved  again. 

10  A.M.  Gave  %  ounce  Rochelle  salt  and  %0  grain  strychnine. 
n  A.M.  Free  watery  bowel  movement. 

11.30  A.M.  Small  watery  bowel  movement.  Patient  is  quiet 
and  comfortable.  Is  sleepy. 

i  P.M.  Patient  has  slept  during  the  last  hour.  Is  sneezing  and 
yawning,  but  says  he  is  not  uncomfortable.  Skin  is  dry.  Pulse, 
85;  respiration,  20;  blood-pressure,  130.  Says  he  is  hungry. 
Gave  glass  of  buttermilk. 

3  P.M.  Patient  has  been  asleep  for  more  than  an  hour.  On 
waking,  he  says  he  is  beginning  to  feel  the  need  of  his  drug. 


Pulse  Tracing  and  Blood-pressure  Records.  123 

Skin  is  moist,  but  is  not  sweating  profusely.  Pulse  is  90 ;  respira- 
tion, 22;  blood-pressure,  systolic  120,  diastolic  100;  pulse-pres- 
sure, 20.  Pulse  tracing  No.  7  taken. 

3.30  P.M.  Gave  %oo  grain  daturine  hypo. 

4  P.M.  Gave  %0o  grain  daturine  hypo. 

9  P.M.  Patient  was  restless  for  about  half  an  hour  after  the 


Tracing  No.  7. 

4  P.M.  hypo,  was  given,  but  before  8  P.M.  had  become  quiet  and 
fallen  asleep  and  has  just  aroused.  Pulse  is  now  80;  respiration, 
20;  blood-pressure,  systolic  130,  diastolic  105;  pulse-pressure,  25. 
Gave  Yioo  grain  daturine  hypo.  Pulse  tracing  No.  8  taken. 

February  ijth,  3  A.M.  About  an  hour  after  the  9  P.M.  hypo, 
was  given  the  patient's  mind  began  to  wander  slightly  and  he 


Tracing  No.  8. 

continued  in  that  condition  practically  without  change  until  within 
the  last  hour.  He  lay  quietly  in  bed  and  would  occasionally  talk 
in  an  indistinct,  mumbling  voice,  but  at  other  times  he  would  not 
speak  or  move  for  half  an  hour  or  more,  was  in  a  semiconscious 
or  dazed  condition.  If  spoken  to  he  would,  at  times,  make  intelli- 
gent answers  and  at  other  times  he  would  not  notice  anything  that 
was  said  to  him.  He  asked  for  water  several  times  and  voided 
urine.  He  has  not  complained  of  any  discomfort  until  within 
the  last  hour.  He  now  says  he  has  some  pain  in  the  legs  and 


124  Narcotic  Drug  Diseases  and  Allied  Ailments. 

back  and  would  like  to  have  something  for  relief.  Pulse,  76; 
temperature,  98%°;  respiration,  16;  blood-pressure,  systolic  120, 
diastolic  98 ;  pulse-pressure,  22.  Pulse  tracing  No.  9  taken. 

3.30  A.M.  Gave  Yioo  grain  daturine  and  60  grains  sodium 
hyposulphite. 

6.30  A.M.  Within  an  hour  after  the  3.30  dose  of  daturine  was 


Tracing  No.  9. 

given  the  patient  lapsed  into  a  semiconscious  dazed  condition  and 
has  continued  so  since.  He  lies  on  the  bed,  talks  to  himself,  and 
occasionally  picks  at  the  bed-clothes,  but  does  not  try  to  get  out 
of  the  bed.  Does  not  complain  of  anything. 

9  A.M.  No  material  change  in  condition  of  patient  from  that 
above  described,  except  that  his  mind  is  becoming  clear  and 


Tracing  No.  10. 

would  like  to  have  something  to  eat.     Gave  30  grains  sodium 
hyposulphite. 

10  A.M.  Patient's  mind  is  entirely  clear.     He  says  he  is  not 
suffering,  but  feels  weak,  and  thinks  a  dose  of  morphine  would 
help  him.    Pulse,  78 ;  respiration,  18 ;  temperature,  98%°  ;  blood- 
pressure,  systolic  130,  diastolic  105;  pulse-pressure,  25.    Tracing 
No.  10  taken.    Gave  %0o  grain  daturine. 

11  A.M.  Patient  fell  asleep  about  three-quarters  of  an  hour 
after  the  last  dose  of  daturine  and  is  now  in  quiet  sleep. 


Heart  Action  under  Daturine.  125 

4  P.M.  Patient  slept  two  hours,  but  has  been  awake  during 
the  last  two  hours.  Says  he  is  not  suffering.  Drank  water  and 
voided  urine.  Gave  30  grains  sodium  hyposulphite. 

6  P.M.  Patient's  mind  has  been  entirely  clear  for  more  than 
an  hour.  Bowels  acted  at  5.30  P.M.  Patient  says  he  is  not  suffer- 
ing, but  would  take  morphine  if  he  had  it.  Gave  %oo  grain 
daturine  and  30  grains  hyposulphite  of  soda. 

11.30  P.M.  Patient's  mind  began  to  wander  about  an  hour 
after  the  6  P.M.  dose  of  daturine  and  he  is  still  in  a  semiconscious 
condition.  He  has  not  been  asleep,  but  has  lain  quietly  on  the 
bed  and  talked  to  himself,  mostly  in  a  whisper. 

February  i8th,  2  A.M.  Patient's  mind  is  entirely  clear;  says 
he  is  comfortable,  and  would  like  to  get  some  sleep.  Gave  10 
grains  of  veronal  and  30  grains  hyposulphite  of  soda. 

10  A.M.  Patient  went  to  sleep  at  3.30  A.M.,  and  has  slept 
soundly  until  a  few  minutes  ago.  Has  just  had  a  free,  watery, 
bilious  action  from  bowel.  Says  he  is  comfortable,  has  no  desire 
for  morphine,  but  wants  something  to  eat.  Gave  glass  of  butter- 
milk and  tub  bath.  Pulse,  70;  respiration,  17;  temperature, 
98%°;  blood-pressure,  systolic  125,  diastolic  100;  pulse-pressure, 

25- 

6  P.M.  Patient  has  been  drowsy  all  day,  has  slept  several 

short  naps.  Bowels  have  acted  four  times,  the  discharges  being 
small  and  bilious,  with  sulphurous  odor.  Patient  says  he  is 
perfectly  comfortable,  but  feels  weak.  Is  hungry.  Has  taken 
buttermilk  several  times  during  the  day.  Gave  2  grains  sparteine 
sulphate  by  mouth. 

10  P.M.  Gave  10  grains  trional. 

February  ipth,  8  A.M.  Patient  passed  a  comfortable  night, 
but  did  not  get  to  sleep  until  2  A.M.  Slept  from  2  to  6  A.M.  Says 
he  feels  like  a  new  man  this  morning  and  wants  a  full  breakfast. 
Says  he  has  no  desire  for  morphine.  His  pulse,  respiration,  and 
temperature  are  normal.  Blood-pressure,  systolic  130,  diastolic 
102;  pulse-pressure,  28.  Light  breakfast  was  given  and  patient 
was  allowed  to  dress  and  get  up. 


126          Narcotic  Drug  Diseases  and  Allied  Ailments. 

8  P.M.  Patient  has  been  up  and  about  the  institution  most  of 
the  day.  Has  spent  a  comfortable  day  and  is  certainly  very  happy 
in  the  realization  of  his  freedom  from  drug  slavery.  Has  not 
asked  for  or  taken  a  dose  of  medicine  of  any  kind  today.  Says 
he  has  no  desire  for  morphine  and  does  not  want  to  take  anything 
that  is  not  actually  necessary.  There  being  no  indication  for  the 
administration  of  medicine,  none  was  given.  His  pulse  is  75; 
respiration,  18;  temperature,  99°;  blood-pressure,  systolic  130, 
diastolic  104;  pulse-pressure,  26.  Pulse  tracing  No.  n  taken. 

10  P.M.  Gave  neutral  bath  and  10  grains  trional. 

February  ipth,  8  A.M.  Patient  had  comfortable  night,  went  to 


Tracing  No.  n. 

sleep  soon  after  getting  out  of  the  bath,  and  slept  three  hours. 
Was  awake  then  for  about  two  hours.  Slept  again  from  4  to  6 
A.M.  Has  just  come  from  dining  room,  where  he  ate  hearty 
breakfast.  Bowels  and  kidneys  acting  normally. 

February  20th,  8  A.M.  Patient's  condition  satisfactory  in  every 
respect  today.  Slept  five  and  a  half  hours  last  night  without 
medicine.  He  ate  three  full  meals  yesterday  and  entertained  the 
other  patients  by  playing  the  piano.  He  had  no  discomfort  at  all 
until  about  5  P.M.,  when  he  said  his  head  and  knees  ached.  His 
temperature  taken  at  that  time  was  99%°.  Ten  grains  aspirin  was 
given,  and  that  relieved  the  aching.  He  had  neutral  bath  at  bed- 
time, but  no  medicine  except  the  single  dose  of  aspirin  was  given. 

February  2$th.  Patient  has  gained  in  strength  and  weight 
during  the  last  five  days.  Has  taken  no  medicine,  except  a  dose 
of  aspirin  occasionally  in  the  late  afternoon.  Is  eating  all  that  he 
is  allowed,  and  that  is  a  fairly  liberal  diet.  Has  slept  from 
four  to  six  hours  each  night  and  has  taken  a  short  nap  during 


Convalescence  Completed.  127 

the  day  on  three  out  of  the  five  days.  Says  he  has  no  desire  for 
morphine  and  that  he  can  hardly  realize  that  he  ever  did  have. 
Is  certainly  making  an  ideal  patient  and  shows  a  determination  to 
secure  and  hold  complete  control  of  himself  that  almost  warrants 
permanency  of  cure. 

February  2$>th.  It  has  been  two  weeks  today  since  the  last 
dose  of  morphine  was  given  in  this  case.  He  has  regained  the 
weight  lost  during  the  active  treatment  and  has  added  10  pounds 
to  that,  making  his  present  weight  160  pounds.  His  mind  is 
bright  and  clear,  and  he  reproduces  accurately  pieces  of  music 
which  he  says  he  has  not  played  for  years.  His  appetite  is 
good ;  in  fact,  rather  too  good,  and  he  has  overtaxed  his  digestive 
organs  during  the  last  few  days.  As  a  consequence  his  bowels 
are  acting  too  often  and  he  does  not  sleep  as  much  as  he  did  the 
first  week.  A  fast  of  a  day  followed  by  a  purgative  was  ordered. 

March  26th.  It  has  been  six  weeks  today  since  the  patient  was 
admitted  to  the  institution  and  over  five  weeks  since  he  had  the 
last  dose  of  any  kind  of  a  narcotic.  During  the  last  four  weeks 
he  has  taken  no  medicine,  except  a  purgative  on  two  occasions. 
His  weight  is  now  175  pounds,  being  a  net  gain  of  25  pounds 
since  beginning  treatment.  During  the  last  three  weeks  he  has 
taken  active  outdoor  exercise  and  says  he  feels  as  well  as  he  ever 
did  in  his  life  and  wants  to  go  to  work.  Dismissed  March  26th. 


CHAPTER  VI. 

TREATMENT  (CONTINUED). 


TREATMENT  OF  DRUG  DISEASE  IN  PREG- 
NANT WOMEN,  ETC. 

IT  would  have  been  extremely  rash  to  have  under- 
taken to  withdraw  an  opiate  by  any  of  the  older  methods 
of  treatment  from  a  pregnant  woman  habituated  to  its 
use.  The  sudden  suppression  of  the  drug  is  attended 
with  such  extreme  distress  that  miscarriage  would  have 
been  inevitable.  The  more  gradual  yet  rapid  with- 
drawal, as  well  as  the  gradual-reduction  method,  is  at- 
tended and  followed  by  diarrhea  and  other  suffering  of 
a  type  which  would  have  almost  certainly  brought  on 
abortion. 

Under  any  of  the  methods  of  withdrawal  which  were 
undertaken  with  the  idea  that  the  drug  itself,  in  the 
system,  constituted  the  real  disease,  diarrhea  of  the  most 
persistent  and_aggravated  kind  always  attended  and  fol- 
lowed the  undertaking.  The  intestinal  contents  were  so 
acrid  that,  after  the  diarrhea  had  proceeded  for  a  few 
days,  the  rectum  became  highly  irritated,  if  not  inflamed. 

The  connection  between  the  nerve  supply  of  the 
rectum  and  uterus  is  very  intimate.  A  rectal  tenesmus 
such  as  often  attends  diarrhea  of  this  character  would 
certainly  excite  sympathetic  uterine  action.  Unless  this 
was  allayed  by  some  drug  of  sufficient  power  to  thor- 
oughly benumb  the  nerve-centers,  emptying  the  uterus 
would  soon  follow.  Therefore,  it  was  considered  out  of 
the  question  to  suppress  the  use  of  a  narcotic  in  a  woman 
habituated  to  its  use  during  the  pregnancy. 
(128) 


Purgatives  for  Pregnant  Women.  129 

With  the  method  introduced  by  the  author  this  is  not 
the  case.  Pregnant  women  can  be  taken  off  of  these 
drugs  with  entire  safety,  if  a  reasonable  degree  of  pre- 
caution is  exercised  in  handling  such  cases. 

In  preparing  such  a  patient  for  the  withdrawal  of 
the  drug,  more  time  should  be  given  in  which  to  free 
the  system  of  toxic  matter  and  more  guarded  use  of 
purgatives  should  be  made ;  but  purgatives  must  be  used, 
because  the  irritating  intestinal  contents  themselves,  if 
allowed  to  remain  in  the  bowel,  will,  as  soon  as  the 
restraining  effects  of  the  opiate  begin  to  die  away,  bring 
on  an  active  and  violent  effort  of  the  bowel  to  empty 
itself. 

In  this  effort  the  system  would  likely  go  to  such 
extremes  as  to  greatly  impair  the  vitality  of  the  patient 
and  bring  on  abortion.  But  if  the  system  is  properly 
cleared  of  the  toxic  matter,  no  diarrhea  follows  and  no 
rectal  or  colonic  irritation  exists;  therefore,  no  sympa- 
thetic uterine  action  is  excited. 

Pregnant  women  stand  purgatives  about  as  well  as 
other  persons  do,  provided  all  functions  concerned  in  the 
evacuation  of  waste  be  stimulated  proportionately  and 
to  a  proper  degree.  The  unnatural  and  unreasonable 
course  almost  universally  followed  by  the  profession, 
that  of  giving  secretory  stimulants  and  depending  on 
them  to  also  excite  the  motor  function  of  the  bowels,  can- 
not be  followed  with  impunity  in  pregnant  women. 

Again,  it  is  well  known  that  certain  remedies  used 
as  purgatives  are  more  drastic  and  irritating  than  others. 
Of  course,  these  should  be  scrupulously  avoided.  The 
two  that  are  in  most  common  use  which  should  not  be 
given  to  pregnant  women  are  aloin  and  podophyllin. 
These  are  objectionable  when  given  to  drug  patients  of 
any  kind,  but  are  especially  so  if  given  to  a  drug  patient 
who  is  pregnant. 


130          Narcotic  Drug  Diseases  and  Allied  Ailments. 

It  is  important  when  preparing  the  purgative  for  a 
drug  habitue  to  compound  one  in  such  a  manner  that  it 
will  act  promptly  and  freely,  but  the  action  of  which  will 
not  be  prolonged.  Podophyllin  is  very  much  inclined 
to  nauseate  in  its  primary  effects,  and  then  its  action  is 
so  persistent  and  continues  to  such  a  degree  as  to  bring 
about  irritation  of  the  colon  and  rectum.  Drug  patients 
do  not  stand  this  well. 

Calomel,  cascara,  and  other  ingredients  noted  in  the 
prescription  suggested  as  a  purgative  for  drug  patients 
can  be  given  to  pregnant  drug  patients  without  any  likeli- 
hood of  disturbing  the  contents  of  the  uterus.  But  after 
the  purgative  has  acted  two  or  three  times,  if  it  shows 
any  disposition  to  continue  the  action,  then  an  opiate 
or  some  other  drug  should  be  given  to  check  excessive 
activity. 

It  takes  more  time  to  prepare  a  pregnant  patient's 
system  for  the  withdrawal  of  the  drug,  but  this  can  be 
done  with  safety  by  careful  administration  of  the  purga- 
tive, and  then  the  drug  may  be  withdrawn  just  as  in 
other  cases. 

The  administration  of  hyoscine  or  scopolamine  may 
be  carried  on  without  any  regard  to  the  pregnancy. 
These  drugs  as  completely  arrest  uterine  action  as  do 
opiates.  There  is  not  likely  to  be  any  rebellion  on  the 
part  of  the  uterus  because  of  the  withdrawal  of  the  opiate 
if  the  patient  is  kept  uniformly,  but  moderately,  under 
the  influence  of  a  drug  of  this  class  for  the  two  or 
three  days  succeeding  the  discontinuance  of  the  opiate. 

The  author  has  taken  a  number  of  pregnant  women 
off  of  morphine  in  this  manner  and  has  not  had  a  mis- 
carriage or  even  a  symptom  that  threatened  one.  Of 
course,  an  undertaking  of  that  kind  is  a  delicate  one 
and  all  precautions  to  prevent  uterine  action  should  be 


Opiate  Should  be  Given  if  Necessary.  131 

used,  but,  while  the  author  has  used  these  precautions, 
they  did  not  really  seem  to  be  necessary. 

The  uterus  was  as  quiescent  under  hyoscine  and  after 
its  discontinuance  as  it  had  been  under  the  narcotic 
effects  of  the  opiate.  Some  of  the  cases  treated  were 
only  two  or  three  months  pregnant,  while  others  were 
well  advanced,  even  up  to  the  seventh  month.  It  is  the 
author's  rule  to  take  every  pregnant  woman  coming 
under  his  care  off  the  drug. 

If  in  the  treatment  of  a  patient  of  this  class  the 
uterus  should  become  rebellious  and  symptoms  of  a  mis- 
carriage set  up,  of  course,  an  opiate  should  be  given  if 
other  remedies  did  not  arrest  this  action,  but  this  would 
not  necessarily  defeat  us  in  our  efforts  at  the  withdrawal 
of  the  drug.  A  single  dose,  or  several  doses,  given  to 
therapeutic  effect  would  not  throw  the  patient  back  into 
the  addiction.  It  would  complicate  matters  somewhat 
and  require  a  longer  time  to  reach  the  normal,  but  these 
therapeutic  doses  of  the  opiate  could  soon  be  counter- 
acted, and  the  patient  still  be  brought  to  a  condition  of 
freedom.  The  author  has  never  had  to  resort  to  an 
opiate  in  any  case  coming  under  his  care  and  it  is  hoped, 
and  believed,  that  others  carrying  out  the  plan  of  treat- 
ment will  have  similar  results. 

TREATMENT    DURING   CONVALESCENCE    OF   ADDICTION 
ACQUIRED  IN  AN  ACUTE  AILMENT. 

In  the  treatment  of  acute  painful  ailments,  such  as 
threatened  abortion,  dysentery,  cardialgia,  renal  or  he- 
patic colic,  etc.,  physicians  are  sometimes  called  upon  to 
administer  opiates  at  frequent  intervals,  if  not  daily,  for 
several  weeks  or  longer.  It  should  be  borne  in  mind 
that,  if  an  opiate  is  administered  daily  for  as  much  as 
four  weeks  in  succession,  addiction  to  the  drug  is  fairly 


132  Narcotic  Drug  Diseases  and  Allied  Ailments. 

established  and  if  the  patient  be  left  to  himself,  and 
knows  what  he  has  been  taking,  he  is  more  likely  to 
continue  to  take  it  than  to  stop  it  merely  because  his 
physician  instructs  him  to  do  so. 

By  the  time  a  patient  has  taken  an  opiate  daily  for 
as  much  as  four  weeks,  a  toxic  condition  of  the  system 
will  have  been  developed  which  will  cause  the  patient  to 
suffer  upon  the  discontinuance  of  the  opiate,  even  if  all 
the  painful  symptoms  of  the  disease  for  the  relief  of 
which  the  opium  was  given  have  subsided. 

If  the  patient  be  discharged  at  this  point,  or  allowed 
to  have  his  own  way,  he  is  likely  to  continue  to  take 
some  form  of  opiate  and  confirmed  addiction  result 

In  threatened  abortion  especially,  it  is  often  necessary 
to  administer  an  opiate  daily  or  oftener  for  a  consider- 
able length  of  time,  in  order  to  carry  the  woman  to  full 
term.  In  such  cases  it  is  best  to  continue  the  opiate  for 
a  few  days  after  the  confinement  and  then  withdraw  it, 
provided,  of  course,  that  no  complication  has  grown  out 
of  the  confinement. 

If  the  confinement  was  a  normal  one  and  no  com- 
plication has  followed  it,  the  patient  should  be  in  as  good 
condition  for  the  withdrawal  within  a  week  after  the 
confinement  as  at  any  other  time,  and  in  such  a  case  as 
this  the  physician  attending  can  carry  out  the  withdrawal 
successfully,  but  he  must  not  shut  his  eyes  to  the  condi- 
tions really  present. 

He  must  recognize  the  fact  that  the  administration 
of  the  drug  for  the  time  it  has  been  given  has  produced 
a  real  pathological  condition,  a  general  systemic  intoxi- 
cation, which  will  not  vanish  at  his  suggestion,  and 
which  will  not  be  cured  by  merely  stopping  the  use  of 
the  drug.  There  is  more  involved  than  merely  stopping 
the  drug,  and  the  author  would  most  strongly  condemn 


Opiates  Withdrawn  During  Convalescence.  133 

any  effort  to  discontinue  the  drug  by  a  mere  gradual 
diminution  of  the  dose. 

The  same  objection  obtains  to  the  gradual  reduction 
method  of  treatment  in  cases  such  as  this,  as  in  the  more 
confirmed  forms  of  addiction,  and  if  possible  these  objec- 
tions are  stronger.  In  these  cases  there  is  no  mental 
element  in  the  addiction.  The  drug  has  only  been  used 
as  a  therapeutic  agent  and  now  that  necessity  no  longer 
exists  for  its  effects  as  such  it  should  be  discontinued, 
but  in  doing  so  particular  care  should  be  exercised  to 
employ  such  a  method  as  to  avoid  the  development  of  a 
mental  element. 

The  reader  is  referred  to  the  chapter  on  Gradual 
Reduction  Method  for  more  full  expression  of  the 
author's  views  as  to  the  damaging  effects  of  this  method 
on  the  mind  of  the  patient. 

The  therapeutic  measures  indicated  in  these  cases 
are  the  same  in  every  respect  as  are  required  in  the 
more  confirmed  forms  of  addiction,  and  for  these  the 
reader  is  referred  to  the  chapters  on  the  Treatment.  It 
should  be  borne  in  mind  that  the  same  toxic  condition 
of  the  system  exists  in  the  recently  formed  addiction  as 
in  the  more  chronic  forms  and  the  same  character  of 
suffering  will  follow  the  withdrawal  of  the  drug. 

It  is  true  that  this  suffering  may  not  be  as  intense  or 
prolonged,  but  it  will  be  more  than  the  patient  can  be 
expected  to  stand  without  assistance. 

The  principle  in  the  treatment,  therefore,  is  the  ad- 
ministration of  a  physiologically  balanced  purgative  in 
the  afternoon,  with  the  usual  quantity  of  opiate  up  to 
bedtime  of  that  day.  On  the  following  morning,  strych- 
nine should  be  given  hypodermically  and  this  followed 
by  a  dose  of  salts  or  oil.  No  opiate  to  be  given  on  this 
morning  until  after  the  bowels  have  acted  freely  several 


134  Narcotic  Drug  Diseases  and  Allied  Ailments. 

times ;  then  the  opiate  should  be  given  in  about  one-half 
the  former  doses.  This  to  be  continued  on  this  and  the 
following  day. 

Forty-eight  hours  from  the  time  of  giving  the  first 
purgative  course,  another  of  similar  character  should  be 
given.  The  opiate  should  be  given  up  to  bedtime  on  this 
day,  but  that  should  be  the  final  dose.  This  purgative 
course  should  be  followed  by  strychnine  and  salts,  or  oil 
as  before.  When  the  second  purgative  course  shall  have 
acted  freely,  the  principal  obstacle  of  the  withdrawal  of 
the  drug  will  have  been  eliminated  from  the  case  and  the 
drug  may  be  withdrawn  with  safety  and  with  but  little 
suffering,  but  it  is  best  to  protect  the  patient  even  from 
this  suffering. 

This  can  be  done  by  the  administration  of  small  doses 
of  hyoscine  or  daturine  for  a  period  of  about  thirty-six 
hours  following  the  action  of  the  second  purgative 
course.  After  that  no  medication  is  indicated  so  far  as 
drug  addiction  is  concerned. 

The  principal  difference  between  a  recently  formed 
and  a  chronic  addiction  is  in  the  fact  that  in  recently 
formed  addiction  the  patient  has  not  become  so  fully 
dependent  on  the  drug  and  the  mental  element,  the 
"mental  habit,"  has  not  become  such  a  dominating  factor. 

In  such  cases,  when  the  physical  demands  for  the 
effects  of  the  drug  have  been  overcome,  the  patient  can 
be  managed  and  controlled  as  any  other  convalescent 
patient  and  the  physician  who  has  succeeded  in  bringing 
the  patient  through  the  acute  ailment  which  made  the 
administration  of  the  opiate  necessary  is  in  favorable 
position  to  administer  the  treatment  indicated  for  the 
cure  of  the  incipient  addiction. 

This  should  be  done  in  every  case  before  the  patient 
is  discharged  from  treatment.  Merely  instructing  the 


Structural  Heart  Lesion.  135 

patient  to  stop  the  use  of  the  opiate  does  not  meet  the 
physician's  responsibility  under  such  circumstances. 

STRUCTURAL  HEART  LESIONS  COMPLICATING 
MORPHINISM. 

The  author  has  frequently  received  inquiries  as  to 
whether  or  not  a  structural  heart  lesion  would  render  it 
unsafe  to  treat  a  patient  for  narcotic  addiction.  There 
is  no  question  but  that  a  structural  lesion  renders  the 
life  of  the  patient  uncertain  at  all  times,  but  the  author 
does  not  feel  that  it  is  at  all  a  contraindication  to  the 
treatment  of  narcotic  drug  addiction ;  in  fact,  if  anything, 
the  patient  is  safer  under  proper  treatment  than  while 
taking  the  opiate. 

When  the  condition  of  the  system  of  a  drug  user  is 
considered,  especially  the  portal  congestion  that  is  habit- 
ual, it  will  be  readily  seen  that  the  heart  is  being  taxed 
constantly  to  propel  the  blood  through  this  obstructed 
area.  This  increased  work  is  not  compensated  for  by 
the  effect  of  the  drug  to  any  great  extent. 

It  is  true  that  morphine  is  a  heart  tonic  to  a  certain 
extent  and  doubtless  in  many  conditions  imparts  greater 
vigor  to  the  heart  action,  but  the  chronic,  prolonged 
effect  of  morphine  could  not  be  so  considered.  There- 
fore, since  the  condition  of  the  system  induced  by  mor- 
phine puts  more  work  on  the  heart,  it  is  the  opinion  of 
the  author  that  the  patient  is  better  off  in  every  respect 
under  treatment  and  afterward  than  he  is  when  taking 
the  morphine. 

The  first  step  in  the  treatment  is  to  unload  the  portal 
system  and  free  the  patient  from  the  accumulated  toxic 
matter,  and  this  reduces  the  work  or  removes  the  ob- 
struction against  which  the  heart  is  propelling  the  blood 
to  a  sufficient  degree,  in  fact  to  more  than  a  sufficient 


136  Narcotic  Drug  Diseases  and  Allied  Ailments. 

degree,  to  compensate  for  any  support  the  heart  received 
from  the  narcotic. 

After  the  period  of  elimination  has  been  passed  and 
the  opiate  is  discontinued,  then  the  next  step  in  the  treat- 
ment is  to  administer  hyoscine,  scopolamine,  or  some 
drug  of  that  class  and  that  is  as  good  a  heart  supportive 
as  is  morphine. 

But  as  an  additional  protective  this  should  be  sup- 
plemented by  the  administration  of  sparteine.  Under 
the  supporting  action  of  these  two  remedies,  the  circula- 
tion is.  uniformly  better,  in  fact  more  satisfactory  in 
every  way,  than  it  is  when  morphine  is  being  used  and 
the  heart  is  laboring  under  the  toxic  condition  which  it 
induces. 

Of  course,  a  patient  with  structural  heart  lesions  of  a 
serious  type  is  always  in  more  or  less  danger,  but  the 
author  does  not  feel  that  such  a  person  is  in  greater 
danger  under  proper  treatment  for  the  cure  of  the  drug 
addiction  than  he  was  before  beginning  it. 

The  author  has  treated  many  cases  with  serious 
structural  heart  lesion,  and,  while  he  cannot  help  but 
feel  apprehensive  when  he  has  such  a  case  under  his 
care,  he  does  not  feel  that  such  a  lesion  should  be  re- 
garded as  a  bar  to  treatment. 

The  care  of  such  cases  is  a  matter  that  would  give 
anyone  concern,  but,  since  the  object  is  to  free  the  patient 
from  a  drug  slavery  which  is  almost,  if  not  altogether, 
as  bad  as  death  itself,  the  undertaking  is  justifiable. 

Of  course,  great  caution  should  be  exercised  in 
the  treatment  of  such  a  case.  Longer  time  should  be 
taken  to  prepare  the  patient  for  the  withdrawal ;  even  if 
it  takes  a  week  or  two  weeks  to  get  the  patient's  system 
free  from  toxic  matter,  it  is  time  well  spent,  especially 
so  since  during  this  time  the  patient's  general  condition 


Sparteine  as  Safeguard.  137 

can  be  improved.    But  with  the  exercise  of  this  precau- 
tion these  cases  bear  treatment  remarkably  well. 

AGE  NOT  A  BAR  TO  TREATMENT. 

The  question  is  often  raised  as  to  the  influence  of  age 
in  determining  the  success  in  the  treatment  of  drug  ad- 
diction. How  old  may  a  person  be  and  still  be  success- 
fully treated  for  an  addiction  ? 

The  question  arises  from  the  general  belief  that  the 
withdrawal  of  a  narcotic  drug  is  attended  by  extreme 
shock  and  suffering  which  would  be  very  dangerous  for 
an  old  person  to  encounter.  That  is  entirely  true  when 
any  of  the  old  methods  of  treatment  are  employed. 
Certainly  no  aged  person  should  be  expected  to  stand 
such  an  ordeal  of  suffering. 

But  with  the  rational  method  of  treatment  which 
removes  the  pathological  condition  involved  as  a  primary 
step  in  the  treatment,  old  persons  can  be  taken  off  the 
drug  as  successfully  as  younger  ones.  Of  course,  the 
same  moderation,  the  same  caution  in  treating  an  old 
person  for  a  drug  addiction,  should  be  used  as  would  be 
requisite  in  treating  such  a  person  for  any  other  ailment ; 
but  with  the  caution  usually  exercised  by  the  profession 
in  treating  aged  persons,  drug  addictions  in  aged  persons 
can  be  successfully  treated. 

No  one  would  think  of  allowing  an  aged  person  to 
continue  to  suffer  from  any  ordinary  ailment  just  be- 
cause of  his  age;  no  more  should  allowing  them  to  con- 
tinue in  drug  slavery  because  of  advanced  age  be  thought 
of. 

It  may  be  suggested  that  they  have  but  little  time 
left,  and  that,  inasmuch  as  they  have  been  using  the  drug, 
many  of  them  a  long  time,  they  should  be  allowed  to  go 
on  without  interference.  This  is  an  unsound  position, 


138  Narcotic  Drug  Diseases  and  Allied  Ailments. 

if  for  no  other  reason,  because  of  the  death  that  such 
persons  will  be  called  upon  to  die.  The  agony  of  suffer- 
ing which  is  likely  to  precede  it  is  almost  beyond 
description. 

The  old  person's  system  is  as  toxic  as  that  of  any 
other  drug  user.  No  other  remedy  will  have  a  normal 
effect  upon  them  as  long  as  they  are  under  the  influence 
of  an  opiate.  Therefore,  when  they  do  fall  sick  of  any 
ailment,  little  relief  can  be  given  them.  Even  a  larger 
quantity  of  the  opiate  than  they  are  accustomed  to  taking 
gives  them  but  little,  if  any,  relief,  certainly  not  enough 
to  overcome  the  distress  incident  to  the  acute  ailment. 
This  holds  good  in  the  last  illness  as  well  as  any  other ; 
in  fact,  it  is  more  noticeable  in  that. 

Almost  all  patients  who  are  habitually  under  the 
influence  of  a  narcotic,  when  seriously  sick,  suffer 
greatly,  and  before  their  death  they  usually  suffer  the 
most  intense  agony,  many  times  dying  in  convulsions 
without  the  slightest  relief  being  available  for  them. 
The  only  remedy  which  could  be  looked  to  for  relief  is 
chloroform  or  ether  and  no  physician  would  be  bold 
enough  to  anesthetize  a  dying  patient. 

Therefore,  these  patients,  if  left  to  continue  the  use 
of  the  opiate,  must  look  forward  to  a  most  agonizing  and 
horrible  death.  To  allow  them  to  face  this  and  continue 
the  use  of  the  drug  simply  because  they  have  not  a  long 
span  of  life  before  them  is  cruelty  of  the  most  extreme 
type. 

The  author  has  had  patients  of  extreme  age,  one  a 
Civil  War  veteran  79  years  of  age.  This  man  was 
wounded  during  the  service  and  for  several  years  after- 
ward suffered  severely  from  complications  growing  out 
of  that  wound,  and  as  a  result  of  this  he  was  given  gum 
opium  for  relief.  When  he  came  for  treatment  he  had 


'Acute  Ailments  in  Drug  Users.  139 

been  using  this  drug  constantly  for  27  years  and  had 
reached  the  age  of  79. 

His  treatment  was  carried  out  without  the  slightest 
complication.  He  suffered  less  from  reactionary  symp- 
toms after  the  withdrawal  of  the  drug  than  young 
persons  do,  and,  while  his  convalescence  was  slow,  it 
progressed  without  any  complications  and  in  a  few 
months  he  was  in  fine  health;  in  fact,  in  much  better 
health  than  he  had  been  for  many  years.  After  spend- 
ing six  weeks  in  the  institution  he  went  home  and  took 
up  his  farm  work.  After  reaching  home,  he  wrote  back, 
saying:  "if  he  knew  he  had  only  ten  days  to  live,  he 
would  come  back  and  be  taken  off  that  enslaving  drug 
so  that  he  might  die  free  from  its  influence." 

Of  course,  patients  of  extreme  age  cannot  be  ex- 
pected to  convalesce  so  rapidly  from  the  anemic  con- 
dition induced  by  the  habitual  use  of  the  drug,  but  that 
would  be  true  if  they  were  sick  with  any  other  ailment. 
Therefore,  their  age  is  no  contraindication  to  treatment. 
They  should  be  given  a  chance  for  freedom  and  the 
author  is  able  to  say  from  observing  the  results  in  quite 
a  number  of  aged  persons  that  they  almost  invariably 
remain  free  from  the  addiction.  This  matter  is  more 
fully  explained  under  the  chapter  on  Prognosis. 

The  longest  continuous  use  of  the  drug  of  any  patient 
who  has  come  under  the  author's  care  is  forty-five  years. 
This  patient  was  65  years  old  and  had  used  morphine 
continuously  from  the  time  she  was  20  years  of  age. 
She  had  tried  a  number  of  home  treatments,  but  had 
never  been  free  from  the  drug  a  day  from  the  time  the 
addiction  was  formed  until  she  came  for  treatment. 

She  had  a  structural  heart  lesion  and  was  subject  to 
slight  spasmodic  asthma,  but,  notwithstanding  these  un- 
favorable conditions,  her  system  was  given  a  general 


140          Narcotic  Drug  Diseases  and  Allied  Ailments. 

renovating  and  she  was  entirely  freed  from  her  addic- 
tion. Her  convalescence  was  slow,  but  successful,  and 
she  was  sent  home  a  free  and  independent  woman,  and 
certainly  as  happy  a  person  as  could  be  found  anywhere. 

One  set  free  from  drug  slavery  after  having  been 
enslaved  for  such  a  period  as  this  feels  that  he  has  been 
given  new  life  indeed,  and  is  as  proud  of  this  new  life 
and  freedom  as  any  other  slave  would  be  who  had  been 
emancipated.  Patients  of  this  class  who  have  been  suc- 
cessfully freed  from  the  addiction  never  cease  to  feel 
grateful  to  the  physician  who  has  brought  them  relief. 
The  author  is  conscious  of  the  fact  that  he  has  made 
stronger  friends  and  more  of  them  in  this  line  of  work 
than  he  could  have  done  in  any  other  field  of  activity. 

Every  drug  patient  is  hopeless,  so  far  as  any  tend- 
ency to  self-recovery  is  concerned.  All  of  them  go  from 
bad  to  worse  and  end  in  either  an  untimely  grave  or  a 
mad-house.  Acute  ailments  of  almost  all  kinds  have  a 
tendency  to  self-recovery  and  a  large  per  cent,  of  those 
who  fall  sick  would  recover,  finally,  without  the  aid  of  a 
physician.  In  drug  cases  no  such  tendency  to  self-re- 
covery exists.  Every  case  is  in  the  class  with  persons 
who  have  a  fatal  malady  which  is  only  curable  by  the 
most  radical  surgical  operation. 

In  such  cases  the  daring  surgeon  goes  in  and  with  his 
knife  removes  the  pathology  and  the  patient's  life  is 
saved.  Without  this,  he  must  necessarily  have  died 
untimely.  This  is  equally  true  in  drug  cases,  and  active, 
intelligent  interference  is  just  as  much  indicated  as  the 
surgeon's  knife  was  in  the  otherwise  incurable  ailment. 

The  pathology  must  be  removed ;  then  the  patient  has 
an  opportunity  to  regain  his  health,  but  to  be  successful 
the  undertaking  must  be  carried  out  with  the  same  degree 
of  thoroughness  with  which  the  surgeon  does  his  work. 


Drug  Patients  Hopeless  Without  Treatment.  141 

The  same  intelligent  care  must  be  exercised  to  cleanse 
the  patient's  system  from  toxic  matter,  even  down  to  the 
toxins  stored  in  the  most  remote,  ultimate  cell,  that  the 
surgeon  exercises  to  see  that  no  break  occurs  in  his 
aseptic  technique. 


CHAPTER  VII. 
CONSIDERATION  OF  THE  REMEDIES   USED. 


PURGATIVES. 

A  THOROUGH,  guarded,  but  effective  use  of  purga- 
tives is  such  an  important  factor  in  the  successful  treat- 
ment of  narcotic  addictions  that  the  author  feels  com- 
pelled to  discuss  the  physiological  law  governing  the 
action  of  purgatives  somewhat  at  length  in  this  work. 

In  the  opinion  of  the  author  no  other  subject  con- 
nected with  the  practice  of  medicine  is  of  equal  impor- 
tance; neither  is  there  one  but  what  is  more  perfectly 
taught,  more  fully  understood. 

The  difficulty  seems  to  arise  from  the  fact  that  our 
medical  teachers  and  writers  take  it  for  granted  that 
everybody  knows  how  to  give  a  purgative,  all  "old 
women"  know  this,  and  certainly  anyone  presuming  to 
take  up  the  study  of  medicine  should  know  that  much  to 
begin  with.  Therefore,  the  subject  is  not  so  thoroughly 
taught  as  its  importance  deserves. 

In  the  author's  opinion  there  are  but  few  men  in  the 
profession  who  understand  the  action  of  purgatives  suffi- 
ciently well  to  enable  them  to  write  for  a  purgative  com- 
pound which  will  effectively  and  proportionately  stimu- 
late all  the  functions  concerned  in  the  evacuation  of  the 
bowel,  and  there  are  fewer  still  who  habitually  write 
their  prescriptions  so  as  to  conform  to  that  standard. 

Purgatives  occupy  such  an  important  place  in  the 

treatment  of  disease  and  have  been  and  are  so  extensively 

used  that  it  would  seem  that  the  principles  upon  which 

their  action  depends  would  long  since  have  become  a 

(142) 


A   Physiologically  Balanced  Purge.  143 

matter  of  common  knowledge,  but  experience  has  con- 
vinced the  author  that  such  is  not  the  case.  In  the 
healing  art,  so  much  depends  upon  the  practical  applica- 
tion of  these  principles  that  every  physician  should 
aspire  to  a  complete  mastery  of  them  and  thereby  be 
saved  from  dependence  upon  the  half-knowledge  of 
empiricism. 

It  should  be  remembered  that  the  key  to  the  secretory 
and  motor  activity  of  the  intestinal  canal,  and  of  the 
glands  emptying  their  products  into  it,  is  the  nerve- 
centers.  Success  in  any  effort  to  secure  evacuation  of 
the  intestinal  contents  depends  upon  the  degree  of 
success  we  have  in  arousing  these  centers  to  functional 
activity.  Our  success  in  that  effort  depends  not  only 
upon  the  condition  of  these  centers,  but  upon  the  manner 
in  which  we  attempt  to  approach  them. 

It  appears  that  many  of  the  agents  causing  disease 
in  the  human  system  exert  a  peculiarly  sedative  influence 
upon  the  nerve-centers  presiding  over  the  motor  activity 
of  the  intestinal  canal.  As  a  consequence  deficient  peri- 
stalsis, manifesting  itself  in  deficient  alvine  dejections,  is 
an  early  symptom  of  almost  all  diseases. 

This  may  or  may  not  be  accompanied  by  deficient 
secretion ;  but  no  matter  how  abundant  secretion  may  be, 
if  the  motor  centers  are  so  blunted  as  to  have  their 
activity  suspended  and  to  be  insensible  to  impressions 
conveyed  to  them,  the  intestinal  tube  becomes  an  inactive, 
motionless  mass  which  effectively  imprisons  its  contents. 

In  the  treatment  of  disease,  if  we  undertake  to  restore 
motor  and  secretory  activity  to  the  intestinal  tube,  we 
have  four  classes  of  agents  which  we  may  employ,  or 
four  modes  of  procedure  at  our  command.  By  two  of 
these  we  can  stimulate  the  nerve-centers  directly;  the 
other  two,  indirectly. 


144  Narcotic  Drug  Diseases  and  Allied  Ailments. 

Direct  stimulation  of  the  cerebrospinal  centers,  if 
sufficient,  arouses  all  the  cells  in  such  centers  to  activity. 
As  a  result  of  this  activity,  secretory  and  motor  impulses 
are  generated  and  transmitted  to  all  the  structures  de- 
riving their  nerve  supply  from  such  centers. 

On  the  other  hand,  indirect  or  reflex  stimulation  of 
such  centers,  unless  very  extensive,  only  arouses  a  part 
of  the  cells  composing  these  centers  to  activity.  The 
motor  or  secretory  response  to  such  stimulation  is  local 
and  not  general.  That  this  statement  may  be  more 
clearly  understood,  the  author  will  advance  this  propo- 
sition : — 

The  same  law  governs  the  generation  and  trans- 
mission of  reflex  motor  impulses  that  governs  the 
circulation  of  the  blood:  "Where  there  is  an  irritation, 
the  blood  will  flow."  Corresponding  exactly  to  this, 
when  the  terminal  filaments  of  the  sensory  nerves  dis- 
tributed to  any  particular  structure  are  irritated  that 
impression  is  transmitted  to  the  centers.  In  response  to 
this,  motor  impulses  are  generated  and  transmitted  to 
the  structure  from  which  such  sensory  impression  came, 
but  to  no  other  structure. 

The  action  is  essentially  local.  In  other  words,  "the 
effect  of  a  given  sensory  stimulus  is  manifested  only  on 
a  limited  and  practically  constant  number  of  motor 
nerves."  //  the  sensory  impression  is  made  upon  the 
nerves  of  a  limited  area,  the  motor  impulse  generated 
in  response  thereto  will  be  reflected  to  correspondingly 
limited  area. 

Much  attention  has  been  given  to  agents  which  stimu- 
late secretion,  and  the  individual  peculiarities  of  these 
agents  have  been  carefully  studied,  but  little  attention 
seems  to  have  been  given  to  the  means  of  exciting  the 
other  function  concerned  in  intestinal  activity. 


Reflex  Stimulation  Local.  145 

It  is  well  known  that  deficient  peristalsis  retards 
bowel  movements,  and  that  if  peristalsis  is  entirely  sus- 
pended no  movements  occur,  but  little  practical  use  is 
made  of  that  knowledge. 

Our  entire  therapeutic  endeavor  seems  to  be  directed 
to  the  stimulation  of  the  secretory  function,  while  little, 
if  any,  attention  is  given  to  the  other  essential  function, 
the  motor  activity  of  the  intestinal  tube. 

The  almost  universal  rule  is  to  administer  secretory 
stimulants  (chemical  irritants)  and  to  trust  to  them,  or 
to  some  vaguely  defined  or  altogether  unknown  agency, 
to  arouse  the  activity  of  the  other  essential  function. 

It  is  true  that  remedies  which  excite  intestinal  secre- 
tion do  also  stimulate  motor  activity  of  the  intestinal 
tube,  but  the  manner  in  which  they  do  this  is  so  inefficient 
and  so  poorly  corresponds  to  the  time  at  which  such 
function  should  be  active  that  it  seems  quite  unreason- 
able to  depend  upon  such  an  agency  for  the  production 
of  so  important  a  factor. 

The  four  modes  by  which  the  secretory  and  motor 
activity  of  the  intestinal  canal  and  of  the  glands  empty- 
ing their  products  into  it  may  be  artificially  induced  are : 
chemical  stimulation;  mechanical  stimulation;  electrical 
stimulation ;  physiological  stimulation. 

CHEMICAL  STIMULATION. 

Chemical  stimulation  is  the  method  almost  univer- 
sally employed;  therefore,  we  shall  first  consider  the 
action  of  this  class  of  agents  and  the  difficulties  encoun- 
tered in  their  employment;  also  the  objections  which 
exist  to  their  being  depended  upon  to  stimulate  the  motor 
function  of  the  bowel. 

Let  us  see  with  what  difficulty  these  agents  accom- 
plish this  dual  result.  Take,  for  example,  the  cholagogue 


10 


146  Narcotic  Drug  Diseases  and  Allied  Ailments. 

cathartics.  These  cause  a  free  flow  of  the  biliary  secre- 
tion. This  secretion  is  poured  into  the  duodenum,  and 
there  it  comes  in  contact  with  the  terminal  filaments  of 
the  nerves  distributed  to  the  intestinal  mucosa,  to  which 
it  is  a  chemical  irritant,  but  it  can  only  stimulate  these 
nerves  as  it  is  brought  in  contact  with  them. 

When  motor  activity  of  the  tube  is  suspended  many 
difficulties  lie  in  the  way  of  its  being  distributed  through- 
out the  length  of  the  tube.  Instead  of  the  small  intestine 
being  a  straight,  patulous  tube  through  which  its  con- 
tents can  readily  pass,  it  lies  in  numerous  convolutions, 
and  at  many  points  a  short  bend  in  the  tube  completely 
closes  its  lumen. 

If  peristalsis  is  suspended  the  downward  passage  of 
the  intestinal  contents  is  effectively  blocked,  thus  con- 
fining any  quantity  of  hepatic  secretion  which  may  have 
been  induced  by  the  action  of  cholagogue  to  the  duo- 
denum and  such  segments  of  the  jejunum  as  it  may  have 
been  able  to  reach. 

If  this  secretion  is  abundant  the  obstruction  to  its 
downward  passage  causes  overdistention  of  that  part  of 
the  tube  which  it  first  reaches  and  in  which  it  is  confined. 
All  the  sensory  nerves  supplying  this  part  send  up  re- 
peated sensory  impressions,  and  the  reflex  response  to 
these  at  times  amounts  to  spasmodic  contractions. 

These  violent  muscular  contractions  mechanically 
irritate  the  sensory  nerves  passing  through  or  terminat- 
ing in  their  fibers.  This  mechanical  stimulation  aug- 
ments the  already  powerful  chemical  stimulation  existing 
in  the  part.  These,  acting  together,  cause  violent 
contractions  of  the  tube,  which  force  the  contents  both 
upward  and  downward. 

If  the  segment  which  is  thus  irritated  be  near  the 
stomach,  bile  and  other  intestinal  contents  are  forced  up 


Mechanism  of  Purgation.  147 

into  the  stomach.  If  lower  down,  these  contractions 
straighten  the  bend  in  the  tube  immediately  below  this 
segment,  thus  allowing  the  contents  to  pass  downward 
to  another  segment  of  the  tube. 

It  is  here  again  arrested  and  held  until  the  irritation 
caused  by  its  presence,  reflexly,  stimulates  this  segment 
of  the  tube  to  such  degree  of  motor  activity  as  to 
straighten  the  bend  at  its  distal  end  and  thus  permit  the 
further  downward  passage  of  the  intestinal  contents. 

This  phenomenon  is  repeated,  segment  by  segment, 
until  the  chemically  irritating  intestinal  contents  have 
gradually,  but  with  difficulty,  worked  their  way  through 
the  entire  length  of  the  tube,  and  then,  but  not  until  then, 
does  evacuation  of  intestinal  contents  begin. 

It  is  evident  that,  since  local  irritation  begets  only 
local  motor  activity,  in  order  to  arouse  peristalsis  extend- 
ing throughout  the  entire  length  of  the  tube,  the  chemical 
irritant,  upon  which  we  are  depending  to  stimulate  such 
function,  must  be  distributed  throughout  the  entire 
length  of  the  tube. 

When  the  motor  centers  are  profoundly  lethargic, 
resulting  in  entire  suspension  of  peristalsis,  this  is  a 
physical  impossibility  except  by  the  tedious  and  difficult 
process  above  described. 

MECHANICAL  STIMULATION. 

Massage  of  the  bowel  is  another  indirect  means  of 
stimulating  the  motor  activity  of  the  intestinal  tube,  but, 
since  in  practising  massage  the  hands  of  the  operator  are 
free  to  move  at  will,  a  large  portion  of  the  surface  of 
the  tube  may  be  stimulated  simultaneously,  thus  sending 
sensory  impressions  from  almost  the  entire  length  of  the 
tube. 


148  Narcotic  Drug  Diseases  and  Allied  Ailments. 

These  impressions  are  responded  to  by  motor  im- 
pulses transmitted  to  a  correspondingly  extensive  area 
of  surface. 

While  this  is  a  reflex  phenomenon,  these  responses 
are  transmitted  in  such  numbers  and  to  such  an  extent 
of  surface  that  they  throw  the  entire  tube  into  a  fair 
degree  of  motor  activity,  resembling,  to  a  considerable 
extent,  peristaltic  waves  generated  by  the  centers  when 
acting  normally. 

In  describing  reflexes  the  older  physiologists  had  in 
mind  only  reflex  movements,  but  at  the  present  time 
physiologists  are  agreed  that  the  reflex  act  affects  not 
only  the  muscles,  voluntary,  involuntary,  and  cardiac, 
but  also  the  glands.  We  have,  therefore,  to  deal  with  the 
reflex  secretion  as  well  as  reflex  motion. 

It  should  be  borne  in  mind  that  by  massage  of  an 
organ  supplied  with  secretory  nerves  the  impressions 
made  on  their  efferent  branches  are  converted  into  secre- 
tory impulses,  and  these  are  transmitted  to  the  organ 
from  which  the  irritation  came  along  with  such  motor 
impulses  as  may  be  excited  by  the  massage. 

Secretion  and  motion  thus  excited  are  distributed 
throughout  the  entire  length  of  the  intestinal  canal,  no 
part  of  the  tube  being  overstimulated  while  other  parts 
are  unreached. 

Massage,  either  by  the  hand  of  a  masseur  or  by  an 
electric  vibrator,  is  a  therapeutic  measure  which  can 
hardly  be  overestimated.  It  can  be  used  with  the  most 
happy  results  in  connection  with  other  measures. 

Another  form  of  massage,  much  less  positive,  but 
none  the  less  valuable  as  a  health  measure,  is  deep  breath- 
ing, forced  abdominal  respiration.  One  who  would 
preserve  his  health  and  keep  himself  in  the  best  working 
trim  will  find  this  an  invaluable  aid  if  faithfully  practised. 


Massage  Excites  General  Peristalsis.  149 

The  best  results  are  obtained  by  devoting  ten  to 
fifteen  minutes  to  the  practice  of  this  exercise  imme- 
diately after  retiring  at  night.  It  should  be  carried  out 
as  follows: — 

Lie  on  the  back,  with  limbs  straight,  or  on  side,  with 
knees  drawn  up ;  then  by  voluntary  efforts  fill  the  lungs 
to  their  utmost  capacity,  until  the  abdominal  muscles  are 
forcibly  distended.  Hold  this  position  about  ten  seconds ; 
then  expel  the  air  from  the  lungs,  at  the  same  time 
forcibly  contracting  the  abdominal  muscles.  Repeat  this 
at  each  inspiration  until  ten  or  fifteen  minutes  have  been 
devoted  to  the  exercise. 

This  alternate  forcible  distention  and  contraction  of 
the  abdominal  walls  changes  the  relation  of  all  parts  of 
the  intestinal  canal  to  each  other,  thus  distributing  and 
mixing  the  bowel  contents.  This  mixing  of  the  intestinal 
contents  promotes  the  normal  chemical  changes,  and 
these  new  compounds  (nature's  stimulant)  induce,  re- 
flexly,  both  secretion  and  motion,  and  the  result  is  more 
complete  evacuation  of  the  waste  products. 

The  mental  concentration  incident  to  the  successful 
carrying  out  of  this  exercise  exerts  a  most  favorable 
influence  upon  the  function  we  are  seeking  to  promote. 
Forced  abdominal  respiration  is  a  voluntary  act,  and,  in 
order  to  carry  it  on  successfully,  the  attention  must  be 
concentrated  upon  it  to  the  exclusion  of  all  other  things. 

Mental  states  greatly  influence  vital  functions. 
Anxiety,  fear,  grief,  excessive  mental  activity,  impair 
digestion,  secretion,  and  excretion. 

Conversely,  concentration  of  the  mental  faculties  in 
an  effort  to  promote  bowel  movement,  even  for  so  short 
a  time  as  fifteen  minutes,  involves  the  cessation  of 
damaging  mental  states.  The  surcease  thus  afforded, 
the  relaxation  and  response  accompanying  it,  give  a 
lethargic  function  a  chance  to  become  active. 


150  Narcotic  Drug  Diseases  and  Allied  Ailments. 

In  many  instances  the  mental  concentration  incident 
to  the  practice  of  massage  by  forced  abdominal  respira- 
tion proves  to  be  hypnotic  to  such  a  degree  that,  before 
the  fifteen  minutes'  exercise  has  been  completed,  the 
subject  is  asleep,  the  subconscious  mind  simply  having 
taken  control  while  the  conscious  mind  was  intently  con- 
centrated upon  the  promotion  of  a  vital  function.  The 
next  morning  a  more  satisfactory  bowel  movement 
occurs.  Is  not  such  a  result  worth  while  ? 

ELECTRICAL  STIMULATION. 

The  motor  centers  can  be  stimulated  to  functional 
activity  by  electricity.  While  this  is  theoretically  true, 
the  author  does  not  believe  that  electrical  stimulation 
can  be  used  to  much  advantage. 

DIRECT  PHYSIOLOGICAL  STIMULATION. 

In  health,  when  the  nerve-centers  are  acting  nor- 
mally, motor  impulses  are  generated  and  rhythmically 
transmitted  to  the  abdominal  viscera.  This  is  mani- 
fested in  the  intestinal  tube  by  waves  of  peristalsis  set- 
ting in  at  the  pylorus  and  extending  throughout  the 
entire  length  of  the  small  intestine.  These  waves  amount 
to  a  worm-like  motion  by  which  every  part  of  the  struc- 
ture of  the  tube  is  changed  in  its  relation  to  other  parts. 

The  uniformity  and  strength  of  these  motor  waves 
depend  upon  the  state  of  activity  of  the  nerve-centers. 
If  these  centers  become  lethargic,  these  waves  are  less 
distinct;  if  they  are  profoundly  blunted,  they  cease  al- 
together. In  disease  they  are  frequently  in  this  inactive 
state;  in  narcotic  addiction  they  are  habitually  so. 

We  have  considered  three  of  the  methods  by  which 
this  inactivity  may  be  overcome,  but  the  fourth,  which 
is  by  far  the  most  valuable  and  efficient,  is  now  to  be 
considered. 


Direct  Stimulation  of  Motor  Centers.  151 

The  functional  activity  of  the  intestinal  tube  depends 
upon  the  nerve-centers.  If  these  centers  are  inactive, 
the  motor  activity  of  the  intestinal  tube,  and  the  secre- 
tory activity  of  the  glands  emptying  their  products  into 
it,  are  correspondingly  impaired  or  suspended. 

In  attempting  to  remedy  such  a  disordered  condition, 
our  first  effort  should  be  to  restore  as  far  as  possible  these 
centers  to  a  state  of  responsiveness.  If  they  have  become 
exhausted  from  overexcitation,  then  sedatives,  motor  de- 
pressants should  be  given;  if  the  suspension  of  their 
activity  is  due  to  the  sedative  effect  of  some  morbid 
poison,  then  remedies  which  will  directly  stimulate  the 
motor  centers  should  be  given. 

It  should  be  constantly  borne  in  mind  that  to  secure 
evacuation  from  the  bowel  it  is  equally  as  necessary  to 
stimulate  activity  of  the  motor  function  of  the  tube  as 
the  secretory  function  of  the  glands. 

The  bile  is  probably  the  normal  stimulant  of  the  in- 
testinal motion,  and  most  substances  used  as  cathartics 
doubtless  act  in  the  same  way.  These  substances  irritate 
the  terminal  filament  of  the  sensory  nerves  distributed 
to  the  intestinal  mucosa.  This  irritation  is  transmitted 
to  the  centers,  and  there  motor  impulses  are  generated 
and  reflected  to  the  point  from  which  the  irritation 
comes,  and  in  this  way  that  part  of  the  intestinal  tube  is 
set  in  motion. 

If  complete  paralysis  exists,  of  course,  no  amount  of 
irritation  will  excite  motion.  Where  paralysis  is  only 
partial,  or  where  the  centers  are  benumbed  by  disease, 
or  have  their  sensibilities  reduced  by  powerful  seda- 
tives, a  higher  degree  of  irritation  is  necessary  to  induce 
peristalsis. 

Agents  which  excite  peristalsis  by  irritation  of  termi- 
nal nerve  filaments  are  frequently  incapable  of  exciting 


152  Narcotic  Drug  Diseases  and  Allied  Ailments. 

such  action  unless  these  centers  arc  brought  into  a  state 
of  responsiveness  by  direct  stimulation. 

The  intestinal  fluid  may  be  an  irritant  to  all  parts  of 
the  mucous  membrane  which  it  reaches,  but,  as  the  tube 
lies  in  numerous  folds,  if  motor  activity  is  impaired  its 
passage  downward  is  much  delayed.  Until  it  has  been 
distributed  downward  to  a  considerable  extent,  enough 
of  the  surface  is  not  irritated  to  cause  peristalsis 
throughout  the  entire  length  of  the  tube. 

In  the  author's  experience  there  are  few  conditions 
which  make  it  best  to  do  indirectly  what  can  be  done 
directly.  It  seems  unreasonable  to  depend  upon  so  ineffi- 
cient and  uncontrollable  an  agency  as  reflex  irritation  to 
induce  peristalsis  when  it  can  be  excited  to  any  degree 
desired,  and  at  the  time  it  is  needed,  by  stimulation  of  the 
motor  centers  with  strychnine. 

Physiologists  teach  us  that  waves  of  peristalsis  set  in 
at  the  pylorus  and  extend  down  the  entire  length  of  the 
tube.  This  is  doubtless  true  in  health,  since  these  waves 
originate  because  of  the  normal  activity  of  the  motor 
centers  and  are  transmitted  throughout  the  entire  length 
of  the  tube,  but  when  the  biochemism  of  the  motor  cells 
is  interfered  with  by  toxins  these  normal  waves  cease 
or  are  much  less  pronounced. 

In  this  condition,  if  it  is  sought  to  excite  peristalsis 
by  introducing  irritating  substances  into  the  intestinal 
canal,  that  part  of  the  canal  to  which  the  irritant  is  ap- 
plied will  be  first  thrown  into  action.  The  contraction 
of  the  tube  thus  induced  urges  the  irritant  downward 
with  greater  or  less  speed. 

But  as  these  substances  make  their  impressions  upon 
each  section  of  the  tube  only  as  they  reach  it,  and  as  the 
motor  impulses  called  out  by  this  irritant  are  reflected 
only  to  that  part  of  the  tube  from  which  the  irritation 


Normal  Peristalsis  Artificially  Induced.  153 

came,  the  tube  is  not  thrown  into  motion  as  a  whole  or  at 
once,  but  section  by  section,  and  only  as  each  section 
receives  motor  impulses  transmitted  to  it  in  response  to 
impressions  made  by  the  irritant  upon  the  nerves  of  that 
particular  section. 

Strychnine  is  an  excitomotor  stimulant  and  has  an 
elective  action  for  the  involuntary  or  unstriped  muscular 
fiber,  and,  as  the  muscular  coat  of  the  intestine  is  com- 
posed of  this  class  of  fibers,  the  entire  length  of  the 
intestinal  tube  can  be  thrown  into  motion  by  direct 
stimulation  of  the  motor  centers  by  this  drug,  without 
materially  affecting  the  voluntary  muscles. 

Peristalsis  induced  in  this  way  corresponds  exactly 
with  that  of  health — that  is,  it  occurs  because  of  the 
artificially  induced  activity  of  all  the  cells  in  the  motor 
centers  controlling  this  function,  and  motor  impulses 
generated  in  response  to  this  artificial  stimulus  are  trans- 
mitted in  a  uniform  degree  to  all  the  structures  that 
would  receive  them  if  the  centers  were  acting  normally. 

The  quantity  of  strychnine  required  and  the  fre- 
quency of  administration  depend  mainly  upon  the  degree 
of  lethargy  or  insensibility  of  the  nerve-centers,  but  when 
strychnine  is  administered  in  sufficient  quantities  and  at 
proper  intervals  active  peristalsis  can  be  excited  and  kept 
up  as  long  as  desired,  provided  the  nerve-centers  are  in 
condition  to  respond  to  any  kind  of  stimulation. 

If  strychnine  be  administered  with  mercurial  or  other 
secretory  stimulant,  each  does  its  part  of  the  necessary 
work  in  bringing  about  the  conditions  essential  for 
normal  evacuation  of  the  bowel. 

The  intestinal  canal  throughout  its  entire  length  is 
thrown  into  normal  or  hypernormal  motion  by  stimula- 
tion of  the  motor  centers  by  strychnine. 

By  increasing  the  irritability  of  the  motor  centers, 
this  agent  brings  those  centers  into  such  a  state  of  sensi- 


154  Narcotic  Drug  Diseases  and  Allied  Ailments. 

tiveness  that  they  readily  respond  to  any  peripheral 
irritation  reflected  to  them.  In  this  way  reflex  stimula- 
tion is  made  to  more  effectively  augment  direct  stimu- 
lation. 

As  soon  as  the  secretion-producing  agent  begins  to 
pour  its  product  into  the  intestinal  canal,  this  secretion 
and  other  intestinal  contents  are  gently,  gradually,  but 
certainly  carried  downward,  thus  bringing  the  chemical 
irritant  into  contact  with  more  extended  surface  of  the 
intestinal  mucosa. 

There  occurs  no  overdistention  of  the  bowel  at  any 
point,  no  retrostalsis,  vomiting,  colic,  or  other  distress. 
In  other  words,  the  conditions  essential  to  normal 
evacuation  of  the  bowel  have  been  in  reality  artificially 
induced,  and  no  more  distress  or  other  discomfort  ac- 
companies the  act  than  if  no  artificial  means  had  been 
used  in  its  induction. 

This  action  is  primary,  direct,  and  sustained.  In- 
crease of  peristalsis  is  one  of  the  early  effects  of  strych- 
nine. This  may  be  noticed  within  thirty  minutes  from 
the  time  of  giving  full  hypodermic  dose,  this  evidently 
being  due  to  its  direct  stimulation  of  the  motor  centers. 

This  effect  of  strychnine  probably  persists  longer 
than  any  other,  or  possibly  it  would  be  more  correct  to 
say  that  intestinal  motion  excited  by  the  strychnine  con- 
tinues after  the  other  effect  of  the  strychnine  has  com- 
pletely subsided.  This  is  due  to  the  fact  that  the  active 
peristalsis  excited  by  the  strychnine  results  in  a  more 
perfect  mixing  of  the  intestinal  contents.  The  chemical 
changes  incident  to  this  augment  the  effect  of  the  strych- 
nine by  increased  reflex  stimulation,  and  this  persists 
after  the  stimulating  effect  of  the  strychnine  has  ceased. 

In  this  connection  the  author  wishes  to  call  attention 
to  the  action  of  the  remedies  of  the  belladonna  group, 


Bowel  Movement  Should  be  Painless.  155 

which  in  this  particular  are  synergistic  to  strychnine. 
Strychnine  increases  the  motor  activity  of  the  intestinal 
canal  by  its  action  as  an  excitomotor  stimulant. 

Atropine,  scopolamine,  hyoscyamine,  daturine,  in 
fact  all  of  the  remedies  of  the  belladonna  group,  excite 
both  secretion  and  intestinal  motion,  but  the  manner  in 
which  they  do  this  seems  not  to  be  well  understood;  at 
least,  it  is  not  clearly  taught  in  therapeutic  works. 

The  author  is  never  satisfied  to  use  any  drug  empiri- 
cally; if  he  cannot  arrive,  at  least,  at  a  plausible  theory 
as  to  its  mode  of  action  he  cannot  use  the  remedy  to 
advantage. 

In  considering  the  action  of  the  belladonna  group  of 
remedies  the  following  view  of  their  action  seems  more 
satisfactory  than  any  other  and  he  believes  it  is  in  accord 
with  established  physiological  law. 

It  is  an  established  principle  that  there  can  be  no 
cause  without  effect.  When  an  effect  is  demonstrated 
its  antecedent  cause  is  assumed.  There  is  no  action  with- 
out a  reaction ;  therefore,  no  reaction  without  a  preceding 
action. 

In  applying  these  principles  of  reasoning  to  the  bella- 
donna group  of  remedies  we  find  that  in  their  primary 
action  they  inhibit  vasoconstriction,  thus  becoming  vaso- 
dilators. This  inhibitory  action  extends  to  the  circular 
muscles  of  the  intestines,  as  well  as  to  the  circular  fibers 
of  the  arterioles  and  capillaries,  and  doubtless  to  the 
circular  fibers  of  the  duct  of  the  lymphatic  system. 

This  inhibitory  action  on  the  circular  fibers  of  the 
intestine  overcomes  irregular  spasmodic  action  in  that 
organ  and  thus  aids  in  preventing  griping  from  the 
effects  of  the  secretory  stimulants.  This  occurs  during 
the  time  the  primary  effects  of  the  remedy  are  active. 

The  same  inhibitory  action  extending  to  the  circular 
fibers  of  the  arterioles  and  capillaries  allows  them  to 


156  Narcotic  Drug  Diseases  and  Allied  Ailments. 

dilate,  thus  rendering  the  peripheral  circulation  more 
active.  The  peripheral  surface  of  the  body  is  the  sensi- 
tive, the  perceptive,  area.  Increased  circulation  in  any 
part  increases  its  sensitiveness.  The  friction  of  the  blood 
or  other  excitant  effects  of  the  increased  circulation  in 
the  surface  of  the  body  stimulate  the  sensory  nerves 
leading  from  that  surface. 

This  stimulation  is  taken  heed  of  by  the  sensory 
terminal  filaments  and  this  expression  of  activity  is 
transmitted  to  the  motor  centers,  and,  being  received  by 
these  centers,  is  responded  to  in  sensory,  motor,  and 
secretory  impulses.  This  impression,  slight  as  it  may  be 
from  any  given  part,  coming  as  it  does  from  the  entire 
peripheral  area,  amounts,  in  the  aggregate,  to  a  positive 
stimulation  of  the  nerve-centers. 

In  other  words,  the  slight  impressions  arising  from 
such  an  extensive  area,  converging  as  they  do  upon  the 
cerebrospinal  centers,  make  a  distinct,  potent  impression 
on  these  centers,  and  this  is  responded  to  by  the  produc- 
tion and  transmission,  to  all  the  structures  governed  by 
such  centers,  of  sensory,  secretory,  or  motor  impulses 
according  to  the  nature  of  the  center  receiving  such 
peripheral  impression. 

Thus  do  the  entire  group  of  belladonna  remedies, 
notwithstanding  they  are  motor  inhibitory  in  their 
primary  action,  become,  secondarily,  exciters,  both  of 
secretion  and  intestinal  motion. 

This  makes  them  invaluable  adjuncts,  if  not  essential 
ingredients,  of  all  purgative  compounds.  After  having, 
by  their  primary  effects,  controlled  spasms  and  prevented 
griping  from  the  effects  of  the  secretory  stimulant,  they, 
at  a  later  and  opportune  time,  supplement  the  effects  of 
such  agents  by  the  augmentation  of  both  secretion  and 
intestinal  motion. 


Mechanism  of  Purgation.  157 

This  action  is  made  more  effective  if  strychnine  has 
been  given  in  combination  with  the  other  ingredients  of 
the  purgative  course.  Excitation  of  the  nerve-centers  by 
strychnine  brings  them  into  a  hypersensitive  state,  and 
makes  them  more  responsive  to  the  reflex  stimulation 
excited  by  the  secondary  action  of  the  remedies  of  the 
belladonna  group. 

A  physiologically  balanced  purgative  compound  is 
one  in  which  each  ingredient  of  the  compound  augments 
and  supplements  the  action  of  the  other,  and  the  whole, 
working  in  complete  harmony,  excites  every  function 
concerned  in  the  evacuation  of  waste  by  the  bowel  pro- 
portionately, but  effectively. 

The  conjoint  effects  of  such  a  combination  insure  the 
evacuation  of  the  bowel  with  the  same  ease  and  freedom 
from  distress  as  if  action  was  voluntary  and  not  artifi- 
cially induced. 

Again,  this  proportionate,  simultaneous  stimulation 
of  all  the  functions  concerned  in  the  bowel  movement 
affects  the  discharge  of  the  waste  without  undue  de- 
pletion. Whereas,  if  chemical  irritants  or  secretory 
stimulants  alone  are  depended  upon,  if  pushed  to  such  a 
degree  as  to  fully  carry  off  the  accumulated  waste,  when 
they  do  begin  to  act,  they  act  excessively  and  unneces- 
sarily deplete  the  patient. 

It  is  important,  as  a  general  rule,  that  undue  deple- 
tion from  the  action  of  purgatives  be  avoided.  It  is 
especially  so  in  the  treatment  of  drug  addictions,  as  they 
are  always  anemic. 

A  physiologically  balanced  purgative  compound,  such 
as  is  herein  outlined,  may  be  depended  upon  to  act  effect- 
ively on  narcotic  habitues;  but  purgative  compounds 
which  do  not  contain  strychnine  and  atropine  or  other 
belladonna  principle  in  sufficient  quantity  to  stimulate 


158 


Narcotic  Drug  Diseases  and  Allied  Ailments. 


active  peristalsis  are  not  only  disappointing  in  their 
action,  but  cause  great  distress. 

Strychnine  and  atropine  given  together  act  syner- 
gistically,  and  a  more  satisfactory  degree  of  peristalsis 
can  be  excited  by  the  two  remedies  combined  than  by 
either  alone.  For  this  purpose  they  are  ideal  agents. 

The  following  schematic  diagram  is  suggested  as 
showing  the  principles  upon  which  a  physiologically 
balanced  purgative  compound  can  be  made. 

A  combination  of  a  suitable  quantity  of  a  remedy  of 
each  of  the  four  classes  here  named  stimulates  every 
function  concerned  in  normal  evacuation  of  the  bowel 
and  brings  about  that  result  zvith  the  least  disturbance 
to  the  system  and  with  the  least  possible  tax  upon  its 

resources. 

'  Calomel. 

Podophyllin. 
Cascara. 
Rhubarb. 
Senna. 
Leptandrin. 
Aloin. 
Bryonia. 
Jalap    or    other 
such  remedy. 


Secretory  stimulant. . 

(May  be  any  one  of 
these  alone  or  two 
or  more  combined.) 


(Castor  oil,  salines?) 


Motor  excitant Strychnine. 

Antispasmodic    Ipecac. 


Vasodilator 


Atropine. 

Hyoscine. 

Hyoscyamine. 

Scopolamine. 

Daturine. 


Also  secretory  stim- 
ulant. 

Also  antispasmodic 
and,  secondarily, 
secretory  stimulant. 


Principles  for  Compounding  Purgatives.  159 

A  purgative  should  never  be  given  on  a  full  stomach. 
If  the  demand  for  its  effect  is  so  urgent  that  there  is  not 
time  to  wait  until  the  stomach  empties  itself,  then  an 
emetic  should  be  given. 

Beginning  with  an  empty  stomach  removes  one  of 
the  causes  of  nausea,  vomiting,  colic,  etc.,  and  does  much 
to  overcome  the  objections  to  the  use  of  purgatives. 

The  remedy  administered  acts  as  a  purgative  because 
its  chemical  or  physical  properties  are  such  as  to  render 
it  unfit  for  use  as  an  article  of  nourishment.  These 
chemical  or  physical  properties  render  it  unacceptable 
or  repulsive  to  the  system — an  irritant.  Because  of 
those  irritating  or  unwholesome  properties,  the  "senti- 
nels on  guard"  set  up  an  active  effort  to  eliminate  it  or 
its  products. 

The  admixture  of  such  an  agent  with  the  stomach 
contents  renders  the  entire  mass  unacceptable  for  assimi- 
lation; therefore,  it  must  either  be  ejected  by  vomit- 
ing or  be  passed  through  the  intestinal  canal  as  wraste, 
being  rendered  unfit  for  assimilation. 

Such  a  bulk  of  matter  in  the  stomach  interferes 
materially  with  the  prompt  and  complete  absorption  of 
the  remedies  given,  thus  delaying,  or  rendering  un- 
certain, their  action.  It  is  either  voided  from  the 
stomach  en  masse  or  passed  precipitately  into  the  small 
intestine,  where  it  greatly  encumbers  that  organ  and 
causes  unnecessary  suffering. 

The  passage  of  incompletely  digested  matter  through 
the  intestines  with  the  numerous  chemical  changes  inci- 
dent to  its  admixture  with  the  other  intestinal  contents, 
together  with  the  irritation  caused  by  the  incompletely 
digested  matter  itself,  is  a  principal  factor  in  the  causa- 
tion of  colic,  griping,  etc.,  as  well  as  the  reflex  nausea 
and  vomiting  which  so  often  precede  or  accompany  the 


160  Narcotic  Drug  Diseases  and  Allied  Ailments. 

action  of  purgatives.  This  distress  is  avoidable  and 
should  be  avoided. 

Few  physicians  give  even  a  moment's  thought  as  to 
the  contents  of  a  patient's  stomach  at  the  time  the  admin- 
istration of  a  purgative  is  begun.  The  patient  may  have 
just  partaken  of  a  hearty  meal,  or  if  not,  if  the  purgative 
is  given  in  divided  doses  through  a  period  of  several 
hours,  he  is  almost  certain  to  "fill  up"  while  he  is  taking 
the  purgative. 

Food  taken  at  such  a  time  is  not  completely  digested, 
and  the  disturbances  of  the  gastrointestinal  canal  pro- 
duced by  the  purgative  cause  it  to  be  either  vomited  or 
pass  downward  from  the  stomach  before  fully  prepared 
for  assimilation,  and  in  either  case  unnecessary  distress 
occurs. 

Since  the  exercise  of  a  little  precaution,  a  little  fore- 
thought, on  the  part  of  the  physician  will  prevent  these 
unpleasant  effects,  this  certainly  should  not  be  allowed 
to  develop.  The  administration  of  a  purgative  should 
not  be  begun  when  there  is  food  in  the  stomach.  None 
should  be  taken  while  the  purgative  is  being  admin- 
istered, and  the  fast  should  be  continued  until  the  purga- 
tive action  has  ceased. 

The  first  meal  after  the  purgative  should  also  be  a 
very  light  one.  After  the  action  of  a  purgative,  even 
after  all  discharges  from  it  have  ceased,  the  digestive 
tract  is  more  or  less  enervated  and  disturbed ;  therefore, 
it  is  not  in  condition  to  undertake  the  digestion  of  a  full 
meal.  If  a  full  meal  be  taken  at  such  a  time,  it  will 
greatly  lessen  the  good  effects  which  would  otherwise 
have  come  from  the  action  of  the  purgative. 

In  the  opinion  of  the  author,  it  is  a  serious  error  to 
administer  an  active  secretory  stimulant  without  at  the 
same  time  making  efficient  provision  for  stimulation  of 


Motion  and  Secretion  Equally  Impaired.  161 

the  motor  function  of  the  intestinal  canal.  Except  in  a 
few  rare  conditions  motor  activity  is  always  as  greatly 
impaired  as  the  secretory  function.  Since  each  of  these 
is  essential  to  satisfactory  bowel  movements,  the  efficient 
stimulation  of  each  should  be  provided  for  in  every  pur- 
gative compound. 

It  is  the  generally  accepted  view  that  all  purgatives 
act  in  one  of  three  ways.  That  is,  by  osmosis,  by  reflex 
stimulation,  or  by  direct  stimulation  of  the  motor  and 
secretory  centers. 

The  osmotic  theory  of  the  action  of  the  saline 
cathartics  has  been  accepted  for  many  years,  but  recently 
doubt  has  been  thrown  upon  the  correctness  of  that  view 
of  their  action. 

Some  years  ago  the  author's  clinical  experience  led 
him  to  the  conclusion  that  the  saline  cathartics  did  not 
traverse  the  entire  intestinal  tube. 

According  to  the  osmotic  theory,  this  concentrated 
alkaline  solution  remained  in  the  intestinal  tube,  and 
because  of  its  affinity  for  water,  and  because  of  the  action 
of  laws  of  osmosis,  fluids  were  attracted  from  the  sur- 
rounding tissues  and  thus  the  flooding  liquid  stools  in- 
duced by  this  class  of  cathartics  were  induced.  If  this 
view  of  their  action  is  correct,  the  salines  do  not  pass 
into  the  circulation  at  all,  but  remain  in  the  intestinal 
tube  and  by  their  chemical  action  attract  fluids. 

This  view  of  their  action  was  accepted  by  the  author 
up  to  the  time  he  began  to  treat  narcotic  habitues,  but 
in  these  cases  their  action  was  so  disappointing  that  he 
was  forced  to  reach  the  conclusion  that  the  intestinal 
tube  could  not  be  fully  emptied  by  the  saline  cathartics. 

This  conclusion  was  reached  from  the  following  state 
of  facts:  Patient  was  admitted  constipated,  but  was 
given  free  colonic  flushing,  removing  everything  from 


162  Narcotic  Drug  Diseases  and  Allied  Ailments. 

the  colon  that  could  be  reached  by  an  enema,  the  same 
being  used  in  the  knee-chest  position.  Then,  Epsom 
salt  was  administered  in  full  doses  and  repeated  until 
from  four  to  six  free  evacuations  occurred. 

It  would  appear  that  the  flushing  actions  of  this 
saline,  preceded  by  the  colonic  flushing,  would  have  fully 
emptied  the  intestinal  canal.  It  seems  certain  that  it 
would  have  done  so  had  the  salts  and  the  fluid  attracted 
to  the  intestine  passed  through  the  entire  length  of  the 
intestinal  tube ;  but  as  a  result  of  the  administration  on 
the  same  day  of  a  physiologically  balanced  purgative 
compound  containing  sufficient  strychnine  to  excite  free 
peristalsis,  the  patient  passed  a  considerable  quantity  of 
semisolid  matter. 

Now,  the  author  does  not  believe  that  this  semisolid 
matter  could  have  remained  in  any  portion  of  the  intes- 
tinal tube  through  which  these  free  watery  discharges 
passed.  Therefore,  he  was  compelled  to  conclude  from 
repeated  experiences  such  as  this  that  the  saline  cathartic 
was  absorbed  from  the  stomach  and  upper  part  of  the 
small  intestine  and  was  excreted  by  the  colon,  most  likely 
by  the  transverse  and  descending  colon,  thus  going 
around  rather  than  through  the  small  intestine. 

The  author  cannot  say  that  this  theory  as  to  the 
action  of  the  saline  cathartics  is  the  correct  one ;  however, 
recently  some  confirmatory  evidence  has  been  secured : — 

"Arthur  F.  Hertz,  Ass't  Physician  Guy's  Hospital 
(Guy's  Hosp.  Rep.,  vol.  Ixiii),  has  shown,  by  administer- 
ing bismuth  preparations  at  various  periods  of  digestion 
and  taking  X-ray  pictures  of  the  abdomen  at  different 
periods  of  digestion,  that  salines  are  really  absorbed  from 
the  stomach  and  upper  bowel  and  probably  excreted  into 
the  lower  intestine.  Hertz,  in  co-operation  with  F.  Cook 
and  E.  G.  Schlesinger,  has  shown  that  when  food  is  taken 


Action  of  Saline  Cathartics.  163 

into  the  stomach  it  reached  the  cecum  in  about  four 
hours.  A  saline  aperient,  on  the  other  hand,  may  cause 
an  action  of  the  bowels  in  some  instances  in  even  half  an 
hour,  and  often  within  two  hours. 

''Insoluble  bismuth  being  administered  with  a  meal 
will  show,  by  radiographs,  the  exact  length  of  time  in 
which  food  passes  down  through  the  different  parts  of 
the  intestine.  A  Seidlitz  powder  or  its  equivalent  taken 
at  the  time  of  the  bismuth  or  with  the  bismuth  and  food 
and  then  radiographs  taken  show  that  the  movement  of 
the  bowel  comes  long  before  the  bismuth  and  food  reach 
the  colon.  The  excess  of  water  excreted,  therefore,  with 
such  movements  cannot  come  from  the  small  intestine, 
as  otherwise  it  would  wash  the  meal  and  the  bismuth 
down  with  it,  but  really  must  be  excreted  into  the  lower 
bowel.  Saline  purgatives  also  seem  to  cause  no  increased 
acceleration  of  passage  of  the  food  from  the  stomach  to 
the  cecum. 

These  investigations  seem  to  show  clinically  that, 
when  it  is  desired  to  empty  the  colon  and  not  act  on  the 
small  intestine,  salines  are  indicated,  but  that,  when  it  is 
desired  to  cause  stimulation  of  excretion  or  of  increased 
peristalsis  or  for  drainage  of  the  upper  bowel,  other 
cathartics  than  salines  are  indicated."  (Jour.  Amer. 
Med.Assoc.) 

The  conclusion  is  inevitable,  it  seems,  from  Hertz's 
experiments  that  the  saline  given  with  the  meal  was 
absorbed  from  the  stomach,  thus  leaving  the  meal  to 
pursue  its  own  course  undisturbed  through  the  bowel, 
its  passage  not  being  hastened  by  the  salines.  Might  it 
not  have  been  that  the  salts  getting  into  the  blood  ren- 
dered the  blood  excessively  alkaline?  This  excessive 
alkalinity  not  being  acceptable  to  the  nerve-centers,  an 
active  effort  for  its  elimination  was  excited,  and,  since 


164  Narcotic  Drug  Diseases  and  Allied  Ailments. 

the  colon  happened  to  be  the  organ  through  which  it  was 
thrown  off,  free,  watery  bowel  movements  resulted. 

The  recent  work  of  Cannon  and  Starling  and  Bliss  by 
which  they  have  demonstrated  the  function  and  motility 
of  the  ascending  colon  leads  the  author  to  suggest  that 
if  the  salines  do  go  into  the  blood  they  are  most  likely 
excreted  by  the  transverse  and  descending  colon,  and 
not  by  the  ascending  colon. 

It  has  been  shown  by  these  gentlemen  that  the  func- 
tional activity  of  the  ascending  colon  very  greatly  resem- 
bles that  of  the  stomach.  It  is  from  this  organ  that  the 
residue  of  nutritive  matter  not  absorbed  higher  up  is 
taken  up  by  the  absorbing  villi. 

The  reverse  peristaltic  waves  which  begin  at  the 
splenic  flexure  of  the  colon  and  travel  backward  to  the 
cecum  serve  to  macerate  and  mix  the  contents  of  this 
part  of  the  intestine,  and  to  force  back  the  more  movable, 
the  liquid,  parts  toward  the  ileocecal  valves,  thus  prevent- 
ing the  too  rapid  passage  of  the  contents  of  this  part  of 
the  bowel  to  the  transverse  and  descending  colon,  and 
giving  more  time  for  the  absorption  of  nutrient  material 
from  it. 

Cannon  has  shown  that  these  reverse  waves  of  con- 
traction are  not  true  peristaltic  waves,  that  is,  they  are 
not  preceded  by  a  zone  of  inhibition,  but  are  mere  con- 
tractions of  the  circular  muscles,  and  that  these  travel 
from  the  splenic  flexure  of  the  colon  to  the  cecum  in 
waves  at  the  rate  of  about  twenty  waves  per  minute. 

These  contractions  of  the  bowel,  running  in  a  reverse 
direction  to  the  normal  peristaltic  wave,  urge  backward 
toward  the  iliocecal  valve  the  more  liquid  contents  of 
the  bowel  and  bring  these  substances  into  intimate  con- 
tact with  the  intestinal  villi,  which  are  absorbing  struc- 
tures. It  is  here  that  the  fluid  portions  of  the  residue 


Reverse  Peristalsis  in  Ascending  Colon.  165 

of  the  products  of  digestion  are  absorbed  and  the  more 
solid  portions  are  formed  into  a  cone  in  the  center  of 
this  part  of  the  intestine.  This  cone  lengthens,  little  by 
little,  by  the  concentric  action  of  the  circular  muscular 
fibers  upon  it,  and  as  this  cone  lengthens  it  projects  into 
the  transverse  colon,  where  it  is  swept  off  by  a  normal 
peristaltic  wave,  running  in  the  usual  direction,  and  is 
transferred  to  the  descending  colon  and  rectum. 

Now,  since  it  is  true,  as  they  have  shown,  that  the 
ascending  colon  is  an  organ  from  which  the  nutritious 
material  is  taken  up,  it  is  not  likely  that  nature  would 
contaminate  such  a  pabulum  by  pouring  into  it  an  un- 
wholesome excretion  of  any  kind.  Therefore,  the  author 
does  not  believe  that  the  ascending  colon  is  an  excreting 
organ  at  all,  but  is  rather  a  macerating  reservoir  from 
which  nutritive  material  is  absorbed. 

Many  physicians  treating  narcotic  drug  addiction 
depend  entirely  upon  saline  cathartics  to  empty  the  pa- 
tient's intestinal  tube.  These  cathartics  do  not  do  this 
work  in  such  a  manner  as  to  give  satisfactory  results. 
They  allow  to  remain  in  the  intestine  considerable  quan- 
tities of  toxic  matter,  the  presence  of  which  accounts 
for  the  nervousness,  the  nausea,  and  many  other  distress- 
ing symptoms  from  which  patients  of  this  kind  suffer 
when  the  salines  alone  are  depended  upon  for  elimination. 

Many  surgeons  also  depend  upon  the  salines  to  empty 
the  intestine  prior  to  operations.  The  author  is  sure 
that  no  such  good  results  can  be  obtained  from  the  salines 
alone  as  can  be  obtained  from  the  administration  of  the 
vegetable  and  mercurial  cathartics  when  combined  with 
strychnine  and  atropine. 

While  the  saline  cathartic  occupies  a  place,  in  fact 
fills  a  place,  that  no  other  cathartic  fills  equally  well,  still 
we  should  discriminate  in  our  use  of  purgatives.  When 


166  Narcotic  Drug  Diseases  and  Allied  Ailments. 

the  action  of  a  saline  cathartic  is  needed  because  of  its 
depleting  effect,  then  it  should  be  given,  but  this  class  of 
agents  does  not  unload  the  entire  primae  vise,  and  should 
not  be  depended  on  for  that  purpose. 

The    following    are    examples    of    physiologically 
balanced  purgative  compounds : — 

^  Hyd.  chlor.  mit., 

Powd.  ext.  cascara aa  gr.  x. 

Powd.  ipecac  gr.  j. 

Strychnine  nit gr.  %  to  %. 

Atropine  sulphate  gr.  %0. 

M.  et  ft.  caps.  no.  4.    Sig. :  One  every  two  hours,  prefer- 
ably at  4,  6,  8,  and  10  P.M.     Fasting. 

3£  Hyd.  submur gr.  v. 

Podophyllin    gr.  j. 

Powd.  ext.  cascara  gr.  x. 

Powd.  ipecac   gr.  j. 

Strychnine  nit gr.  %  to  %. 

Atropine  sulphate   gr.  %0. 

M.  et  ft.  caps.  no.  4.     Sig. :    One  every  two  hours,  on 
empty  stomach. 

For  Aged  Person  When  Mercury  is  Objectionable. 

I£   Podophyllin    gr.  j. 

Aloin   gr.  ij. 

Powd.  ext.  cascara  gr.  x. 

Ipecac    gr.  j. 

Strychnine  nit gr.  %  to  %. 

Atropine  sulphate  gr.  %0- 

M.  et  ft.  caps.  no.  4.     Sig.:    One  every  two  hours,  on 
empty  stomach. 


Physiologically  Balanced  Purgative.  167 

1^   Povvd.  ext  rhei, 

Powd.  ext.  senna   aa  gr.  x. 

Podophyllin    gr.  ss. 

Ipecac    gr.  j. 

Strychnine  nit gr.  %  to  %. 

Atropine  sulphate   gr.  Y50. 

M.  et  ft.  caps.  no.  4.     Sig. :    One  every  two  hours,  on 
empty  stomach. 

If  patient  is  addicted  to  the  habitual  use  of  a  narcotic 
drug,  the  strychnine  in  any  of  the  above  formulas  should 
be  increased  from  50  to  100  per  cent. 

3^  Aloin    gr.  ss. 

Strychnine    gr.  %0- 

Ext.  belladonna  ST-  Vs- 

Ipecac  gr.  %6. 

Make  one  pill. 

The  above  is  the  lapactic  pill  formula  and  is  one  of 
the  most  valuable  ever  written,  but  it  is  more  strictly 
an  evacuant  than  a  purgative.  It  is  one  of  the  few 
formulae  in  popular  use  wThich  measures  up  to  the  stand- 
ard to  which,  the  author  contends,  all  purgative  com- 
pounds should  be  made  to  conform. 


CHAPTER  VIII. 

TREATMENT  (CONTINUED). 


REMEDIES  EMPLOYED. 
HYOSCINE,  SCOPOLAMINE,  DATURINE,  ETC. 

SECOND  only  to  the  usefulness  of  purgatives  in  the 
treatment  of  narcotic  addiction  is  hyoscine,  scopolamine, 
daturine,  or  some  other  member  of  the  solanaceous 
group  of  remedies. 

Hyoscine,  made  from  hyoscyamus,  is  considered  by 
many  to  be  the  most  uniformly  satisfactory  member  of 
this  group,  but  the  difficulty  in  obtaining  real  hyoscine 
during  the  last  several  years  has  been  very  great  and 
practically  all  orders  for  hyoscine  have  been  filled  from 
the  stock  of  scopolamine,  with  which  it  is  claimed  to  be 
chemically  and  physiologically  identical. 

As  to  its  chemical  identity  the  author  cannot  say,  but, 
as  to  the  physiological  effects  of  hyoscine  made  from 
hyoscyamus  and  scopolamine  made  from  the  other  mem- 
bers of  the  solanaceous  group,  the  author  is  able  to  say 
that  they  are  to  all  intents  and  purposes  identical,  but  the 
effects  of  these  two  members  of  the  group  differ  in  some 
essential  points  from  the  effects  of  atropine  and  daturine. 
It  is  to  points  of  difference  rather  than  to  their  physio- 
logical effects  in  general  that  the  author  wishes  to  direct 
attention. 

The  physiological  effects  of  these  remedies  are  well 
understood,  in  a  general  way,  and  are  sufficiently  dwelt 
upon  by  writers  on  therapeutics.  But  in  the  matter  of 
comparing  their  effects,  one  with  another,  when  used  in 
the  treatment  of  narcotic  addiction,  the  author's  exten- 
(168) 


Hyoscine  and  Scopolamine  Identical.  169 

sive  experience  with  these  remedies  in  the  treatment  of 
this  class  of  ailments  has  afforded  him  an  opportunity 
to  draw  conclusions  which  writers  on  therapeutics  have 
not  had. 

The  effects  of  this  class  of  remedies  on  the  heart 
action  are  tonic  and  supportive:  "In  some  subjects  a 
decided  slowing  of  the  heart  takes  place  immediately 
after  the  administration  of  a  considerable  dose  of  any 
one  of  these  remedies,  and  in  all,  most  probably,  an  in- 
stantaneous retardation  of  the  pulse  rate,  but  a  very 
decided  rise  in  the  number  of  pulsations,  quickly  follows. 
Not  only  is  the  number  of  heart  beats  increased,  but  their 
vigor  also  and  the  area  over  which  pulsations  are  dis- 
tributed are  enlarged. 

"It  has  been  conclusively  shown  that  the  increased 
action  of  the  heart  is  due,  first,  to  stimulation  of  the 
cardiac  ganglia  of  the  sympathetic  and,  secondarily,  to 
a  paralyzing  action  on  the  pneumogastric  terminal  fila- 
ments. In  other  words,  the  motor  power  of  the  heart  is 
increased  in  activity  and  the  inhibiting  control  is 
lessened." 

"The  more  rapid  action  of  the  heart,  increased  respiratory 
movements,  the  contraction  of  the  arterioles  result  in  an  increased 
supply  of  blood  to  the  periphery,  more  rapid  nutritive  changes, 
and  consequent  elevation  of  the  temperature.  The  rise  in  tem- 
perature in  man  from  a  full  medicinal  dose  is  from  %°  to  i°  F. 
This  increased  body  heat  is  not  long  maintained ;  with  the  fall  of 
blood-pressure  (vasoparesis)  there  ensues  a  diminution  in  the 
temperature. 

"They  are  all  distinctly  respiratory  stimulants,  both  the 
number  and  depth  of  the  respiratory  movements  being  increased 
by  them,  but  this  increase  is  not  in  the  same  ratio  as  the  elevation 
of  the  pulse  beat,  the  pulse  rate  being  also  reduced  in  frequency, 
but  the  volume  is  sustained." 


170  Narcotic  Drug  Diseases  and  Allied  Ailments. 

Hyoscine  and  scopolamine  are  decidedly  more  hyp- 
notic in  their  effects  than  the  other  members  of  this 
group.  In  the  matter  of  duration  of  effects,  daturine 
seems  to  differ  from  the  others  to  a  considerable  degree. 
It  is  somewhat  slower  in  action  than  hyoscine,  but  when 
the  patient  is  fully  impressed  by  its  effects  this  effect 
continues,  holding  practically  a  uniform  degree,  about 
twice  as  long  as  do  the  effects  of  hyoscine. 

When  a  patient  is  brought  to  a  certain  degree  under 
the  effects  of  hyoscine  it  will,  as  a  rule,  be  necessary  to 
administer  hyoscine  about  every  three  hours  to  maintain 
the  same  degree  of  effect,  whereas  if  daturine  is  em- 
ployed instead  of  hyoscine  it  is  not,  ordinarily,  necessary 
to  repeat  it  oftener  than  once  in  six  hours  to  maintain 
the  same  degree  of  effect. 

Daturine  does  not  dry  the  mucous  membrane  of  the 
mouth  or  throat  so  greatly  as  do  the  other  remedies  of 
this  class;  neither  are  the  mental  symptoms  induced  by 
it  so  active.  The  patient  lies  in  bed  in  an  inactive,  some- 
what dazed  condition,  his  mind  clear  enough  to  make 
intelligent  answers  to  questions,  but  if  left  to  himself  he 
has  nothing  to  say,  but  passes  the  time  in  a  dreamy 
semisleep. 

This  is  a  most  satisfactory  condition  in  which  to  keep 
the  patient  for  the  forty-eight  or  more  hours  following 
the  withdrawal  of  the  drug,  but  drug  patients  cannot  be 
brought  and  kept  in  this  condition  of  dreamy  semisleep 
unless  the  system  has  been  thoroughly  cleansed  of  toxic 
matter  before  the  opiate  is  withdrawn. 

If  the  administration  of  any  of  these  agents  is  begun 
while  the  system  is  still  toxic,  their  effects  will  be  most 
disagreeable  and,  in  order  to  relieve  the  patient's  suffer- 
ing, will  have  to  be  administered  so  freely  as  to  establish 
an  active  delirium.  This  is  very  unpleasant,  both  to  the 


Hyoscine  and  Daturine,  Effects  Compared.  171 

patient  and  the  attendant,  and  should  be  scrupulously 
avoided. 

In  former  chapters  enough  has  been  said  as  to  the 
effect  of  hyoscine  in  the  treatment  of  drug  addiction  to 
show  that  it  occupies  an  important  place,  but  there  is 
one  phase  of  its  curative  value  which  has  not  been  fully 
shown. 

We  have  seen  that  in  the  treatment  of  drug  addiction 
we  are  dealing  with  a  toxemia,  a  drug,  auto-,  and  intes- 
tinal toxemia.  All  the  nerve-centers,  in  fact  the  entire 
nervous  system,  have  been  persistently  restrained  by  the 
effects  of  the  opiate.  This  has  permitted  all  the  struc- 
tures of  the  body,  even  the  cells  themselves,  to  become 
saturated  with  toxic  matter. 

A  generally  inactive  state,  a  semiparalysis  of  all  the 
eliminating  organs,  has  become,  habitually,  the  bodily 
state.  By  the  free  administration  of  purgatives  the  bulk 
of  this  poisonous  matter  can  be  evacuated,  but  it  is  evi- 
dent that  the  deeper  seated,  more  lethargic  tissues — the 
ultimate  cells — cannot  at  once  be  made  to  throw  off  all 
the  accumulated  toxic  matter.  A  perceptible  and  damag- 
ing residue  will  be  left  in  them,  no  matter  how  thor- 
oughly the  elimination  by  purgatives  has  been  carried 
out. 

Now,  the  withdrawal  of  the  opiate  and  the  adminis- 
tration of  hyoscine  establish  a  state  of  general  hyperes- 
thesia  during  the  continuation  of  which  all  the  nerve- 
centers  are  unusually  active.  The  increased  activity  of 
the  nerve-centers  gives  rise  to  greatly  increased  motor 
and  secretory  impulses,  which  are  transmitted  to  all  the 
structures.  This  is  especially  helpful  in  bringing  the 
deeper  seated,  more  lethargic  structures  to  throw  off  any 
residue  of  toxic  matter  remaining  in  them. 

Therefore,  hyoscine  or  other  remedy  of  this  group  is 
in  this  additional  sense  a  helpful  factor  in  the  successful 


172  Narcotic  Drug  Diseases  and  Allied  Ailments. 

treatment  of  narcotic  disease.  Patients  to  whom  it  has 
been  properly  and  discreetly  given  reach  a  normal  con- 
dition in  much  less  time  than  do  those  who  have  not 
taken  it. 

It  is  true  that  there  would  be  a  general  awakening  of 
the  nerve-centers  following  the  withdrawal  of  opiates, 
which  would,  finally,  lead  to  the  throwing  off  of  the  re- 
mainder of  toxic  matter,  but  hyoscine  brings  this  about 
much  more  effectively  and  more  promptly  than  the  un- 
aided restorative  forces  of  nature. 

The  most  pleasing  feature  of  this  hyperactivity  of 
the  nerve-centers  is  shown  in  the  patient's  mental  condi- 
tion. The  gloomy,  despondent  condition  which  has  been 
so  constant  gives  way  to  one  of  vivacity  and  brightness. 
So  distinctly  is  this  the  case  that  the  patient  himself  will 
notice  it  and  remark  about  it.  This  is  a  very  pleasing 
and  encouraging  feature  and  one  in  which  most  patients 
take  a  very  keen  interest. 

For  one  whose  mind  has  been  so  lethargic  that  he 
could  with  difficulty  recall  the  most  commonplace  experi- 
ence of  his  life  to  wake  up  with  a  revivified  memory  of 
all  these  events,  and  to  be  able  to  recall  them  with 
promptness  and  accuracy,  is  a  most  delightful  experience. 
Especially  is  this  true  with  the  more  highly  educated  and 
ambitious  patients. 

The  author  having  been  the  first  to  direct  the  atten- 
tion of  the  profession  to  hyoscine  (scopolamine)  as  a 
remedy  capable  of  relieving  the  suffering  incident  to 
the  abrupt  withdrawal  of  opiates  and  materially  aiding 
in  the  cure  of  narcotic  drug  addiction,  he  has  felt  it  his 
duty  to  stand  sponsor,  as  it  were,  for  the  remedy. 

In  this  capacity  he  has  found  it  necessary  to  defend 
the  remedy  from  the  attacks  of  its  enemies,  as  well  as 
from  its  overzealous  friends.  And,  now,  after  a  period 


Advantages  of  Hyoscine,  173 

of  more  than  ten  years  he  feels  justified  in  saying  that 
the  overenthusiastic  friends  of  the  remedy  have  done 
more  to  disparage  its  use  than  those  who  were  openly 
opposed  to  it.  Their  advocacy  of  hyoscine  (scopolam- 
ine)  as  a  specific  cure  of  the  morphine  addiction  has 
led  to  its  ill-advised  and  extravagant  use. 

The  effects  of  the  remedy  when  given  in  excessive 
doses  or  when  the  patient  has  not  been  properly  prepared 
for  it  are  extremely  unpleasant.  This  has  created  a 
prejudice  against  the  remedy  in  the  minds  of  those  who 
have  been  unfortunate  enough  to  have  it  tried  upon  them 
in  this  manner  or  under  these  conditions.  This  is  to  be 
regretted,  since  persons  who  have  had  such  an  experi- 
ence with  it  are  not  likely  now  to  seek  the  benefits  they 
might  derive  from  its  proper  use.  This  is  unfortunate, 
because  those  who  have  been  thus  disappointed  may  con- 
tinue in  slavery  under  the  belief  that  there  is  no  relief  for 
them. 

While  it  is  unquestionably  true  that  there  are  many 
persons  who  can  take  hyoscine  (scopolamine)  in  large 
doses  for  days  at  a  time  without  danger  to  life,  the 
author  is  equally  certain  that  there  are  others  who  can- 
not do  so,  and,  as  no  one  is  capable  of  judging  before- 
hand which  of  these  classes  of  patients  he  is  undertaking 
to  treat,  one  is  not  justified  in  giving  excessive  doses 
until  the  tolerance  of  the  patient  has  been  fully 
ascertained. 

The  most  "liberal"  use  of  hyoscine  (scopolamine) 
which  has  been  brought  to  the  author's  attention  is 
reported  by  Rosenberger  in  Medical  News,  Nov.,  1902. 

This  patient  was  a  male  53  years  of  age  taking  30  to 
60  grains  of  morphine  per  day.  Following  the  teach- 
ings of  Lott,  that  hyoscine  is  a  specific  cure  for  the 
morphine  addiction,  Rosenberger  kept  up  the  adminis- 


174  Narcotic  Drug  Diseases  and  Allied  Ailments. 

tration  of  hyoscine  in  this  case  fifteen  days,  during  which 
time  hyoscine  equivalent  to  188  Vice-grain  doses  was 
administered  to  this  patient. 

On  the  fourth,  fifth,  sixth,  seventh,  and  a  part  of 
the  eighth  day  Vioo  grain  of  hyoscine  was  given,  hypo- 
dermically,  every  hour.  The  doctor  says  that  "during 
these  days  the  patient  was  less  restless,  slept  several 
hours  of  the  time,  and  looked  brighter.  His  skin  became 
very  hyperesthetic,  and,  if  touched  ever  so  lightly,  severe 
muscular  twitchings  were  produced.  The  respiration 
was  from  12  to  18  per  minute;  pulse,  84  to  60.  Bowels 
were  evacuated  twice  during  these  five  days.  Urine  on 
the  fourth  day  was  29  ounces ;  fifth  day  22  ounces ;  sixth 
day  12  ounces;  seventh  day  14  ounces;  eighth  day  27 
ounces.  The  hyoscine  during  the  latter  part  of  the 
eighth  day  was  reduced  to  -J/ioo  grain  every  two  hours. 
At  this  time  a  bright-red  rash  developed  by  the  side  of 
the  spine,  knees,  legs,  body,  and  face." 

That  a  record  of  the  extremely  disagreeable  symp- 
toms which  may  be  expected  to  follow  this  excessive  use 
of  hyoscine  may  be  preserved,  the  following  quotations 
from  the  doctor's  paper  are  made : — 

"During  this  time,  that  is,  from  the  fourth  to  the  eighth  day, 
above  quoted,  his  talk  was  unintelligible,  partly  on  account  of  the 
dryness  of  the  mouth  and  tongue.  The  latter  organ  felt  as  dry 
and  hard  as  a  splintered  board. 

"On  the  ninth  day  he  voided  37  ounces  of  urine,  and  on  the 
tenth  day,  40  ounces ;  on  the  eleventh  day,  54  ounces  at  one  time 
and  26  ounces  at  another;  on  the  twelfth  day,  34  ounces;  the 
thirteenth  day,  43  ounces,  36  at  one  time  and  7  at  the  second 
urination;  fourteenth  day  no  urine  voided  at  all  and  no  bowel 
movement;  fifteenth  day  53  ounces  at  one  time,  10  ounces  at 
another,  and  7  ounces  at  the  third. 


Excessive  Use  of  Hyoscine.  175 

"The  patient  was  quiet,  especially  after  each  injection,  and 
on  the  tenth  day  he  begged  for  a  hypodermic  of  morphine  or  pill 
of  morphine.  After  a  severe  lecture  he  quieted  down  and  never 
asked  for  the  drug  again.  The  pulse  ranged  between  62  and  84 ; 
respiration,  1 8  to  22  per  minute. 

"The  patient  now  began  to  feel  stronger  and  became  able  to 
help  himself  more.  At  times  he  still  picked  at  the  bed-clothes 
and  was  heard  mumbling  about  money  matters  or  some  one 
stealing  from  him,  and  not  until  the  eighth  or  ninth  day  was  he 
able  to  identify  anyone.  If  attempts  were  made  to  force  him  to 
drink  he  would  spit  the  milk  in  the  attendant's  face  without 
warning.  The  tongue  still  remained  hard,  though  after  several 
days'  moistening  with  glycerin  it  gradually  became  soft  and  more 
moist. 

"After  the  twelfth  day  the  hyoscine,  %oo  grain,  was  given 
every  three  hours,  and  strychnine  nitrate  four  times  a  day.  The 
hyoscine  was  stopped  entirely  on  the  fifteenth  day.  Up  to  this 
time  he  had  taken  I2%5  grains  of  hyoscine  in  fourteen  days. 
Strychnine  in  the  form  of  nitrate,  %0  grain  four  times  a  day,  was 
the  only  medicine  given  from  now  on. 

"The  bowels  had  been  evacuated  once  a  day,  sometimes  once 
in  two  days.  After  the  seventh  day  the  bowels  were  evacuated 
two,  three,  or  four  times  a  day.  The  stools  were  liquid  in  char- 
acter and  attended  by  some  pain.  As  this  became  persistent, 
suppositories  of  bismuth  subgallate,  20  grains  each,  every  three  or 
four  hours  were  given  with  beneficial  results. 

"Insomnia  now  bothered  the  patient.  This  was  controlled 
by  trional  in  doses  of  20  grains  in  hot  water.  A  dose  of  hyoscine, 
Koo  gram>  was  also  given  in  conjunction  with  the  trional. 

"On  the  eighteenth  day  he  insisted  that  it  was  impossible  for 
him  to  get  along  without  morphine,  so  we  compromised  by  giving 
him  y5  grain  of  apomorphine  hypodermically,  with  the  satisfac- 
tion of  seeing  him  much  quieter  and  less  obstreperous.  No 
vomiting  or  even  nausea  was  produced  by  this  dose  of  apo- 
morphine. 


176  Narcotic  Drug  Diseases  and  Allied  Ailments. 

'Trional  was  now  given  twice  daily  with  apomorphine,  %0 
grain.  On  account  of  the  great  restlessness  and  nervousness,  the 
mixture  containing  sodium  bromide,  20  grains,  was  given  three 
times  a  day.  From  the  eighteenth  to  the  twenty-fifth  day  he 
gained  strength  daily  and  ate  readily  of  pretty  nearly  everything, 
though  in  the  first  two  weeks  a  liquid  diet  of  milk  and  eggnog 
was  prescribed  for  him.  Convalescence  was  rapid  and  marred 
only  by  a  slight  diarrhea,  seven  or  eight  movements  daily,  which 
was  readily  controlled  by  the  bismuth  subgallate  suppositories." 

This  case  is  quoted  at  this  length  because  the  author 
feels  that  some  comment  should  be  made  upon  it.  One 
can  hardly  imagine  a  more  distressing  condition  than 
that  of  the  patient's  mouth  and  tongue  while  under  this 
remedy  to  this  excessive  degree.  The  statement  that  his 
"tongue  was  as  dry  and  hard  as  a  board"  is  enough  to 
warn  anyone  against  putting  the  patient  into  that  state. 

It  is  evident  that  during  most  of  these  days  the 
patient  was  not  able  to  take  nourishment  of  any  kind. 
This  evidently  allowed  the  physical  strength  to  run  down 
very  greatly  and,  as  the  patient  was  still  to  be  taxed  by 
diarrhea  in  the  latter  part  of  the  treatment,  it  does  not 
occur  to  the  author  that  the  patient  received  any  benefit 
from  the  administration  of  hyoscine. 

Again,  the  author  wishes  to  call  attention  to  the  con- 
dition of  the  bladder.  The  statement  that  the  bladder 
was  allowed  to  fill  to  such  an  extent  as  to  contain  as 
much  as  50  or  58  ounces  of  urine  at  one  time  is  alone 
enough  to  condemn  this  excessive  use  of  hyoscine.  The 
distention  of  the  bladder  to  that  degree  is  almost  certain 
to  be  followed  by  a  cystitis,  a  most  distressing  ailment, 
and  one  which  would  call  strongly  for  a  narcotic. 

But  even  that  danger  might  be  risked  if  the  excessive 
administration  of  hyoscine  really  cured  the  patient,  but  it 


Excessive  Use  of  Hyoscine.  177 

does  not  do  so.  In  the  author's  opinion,  this  patient 
would  have  been  infinitely  better  off  had  he  been  given 
an  active  purgative  and  the  morphine  discontinued  at 
once  without  the  administration  of  hyoscine.  Then  he 
could,  in  a  few  days'  time,  have  fought  out  the  battle 
with  the  majority  of  these  complications  and  would 
doubtless  have  emerged  from  the  ordeal  with  much  more 
physical  vigor  and  a  much  better  chance  to  regain  his 
footing  than  he  had  after  this  long  seige  of  dosing,  sup- 
posed to  be  a  curative  treatment.  After  this  was  all  over 
he  still  had  equally  as  hard  a  fight  to  make  with  the  com- 
plications which  followed  the  discontinuance  of  the  drug 
as  he  would  have  had  to  make  had  none  of  this  treatment 
been  given. 

The  doctor  thinks  his  patient  was  cured,  but  in  the 
judgment  of  the  author  between  the  eighteenth  and 
twenty-fifth  day,  when  his  rapid  convalescence  began,  it 
is  more  than  likely  that  the  patient,  by  some  means, 
secured  an  opiate,  and  it  was  the  taking  of  this  that 
restored  his  condition  to  such  a  degree  that  he  could 
eat  and  begin  convalescence. 

In  attempting  to  treat  patients  of  this  class  at  their 
homes,  or  in  the  wards  of  a  general  hospital,  the  phy- 
sician never  knows  that  the  patient  does  not  get  drugs 
which  he  does  not  order  for  him.  Sympathetic  friends, 
or  others  with  whom  the  patient  can  have  contact,  will 
frequently  yield  to  his  importunities  and  bring  him  some- 
thing that  will  defeat  the  best  efforts  made  in  his  behalf. 

It  is  evident  that  this  patient's  system  was  about  as 
toxic  as  it  could  have  been  consistent  with  the  continu- 
ance of  the  functions  of  organic  life.  Any  sudden  im- 
provement of  the  patient,  the  sudden  cessation  of  the 
distressing  symptoms,  will  warn  one  of  experience  that  a 
drug  has  been  secured  from  the  outside  and  is  being 


12 


178  Narcotic  Drug  Diseases  and  Allied  Ailments. 

taken,  and  that  that  accounts  for  the  sudden  cessation 
of  the  distressing  symptoms  and  for  the  rapid  improve- 
ment in  the  condition  of  the  patient.  While  it  is  possible 
for  such  a  change  to  be  due  to  improvement  in  his  phys- 
ical condition,  it  is  often  quite  the  reverse  from  progress 
toward  final  freedom. 

A  physician  in  the  West  reports  a  patient  taking  20 
grains  of  morphine  per  day  in  which  he  gave  65  Vioo- 
grain  doses  of  hyoscine  during  the  period  of  two  and 
one-half  days,  being  over  %0o  grain  every  hour  for  that 
length  of  time.  He  says  that  the  patient  was  dis- 
charged cured.  In  another  case  this  physician  notes  that 
a  patient  using  large  quantities  of  morphine  and  cocaine 
daily  was  treated  for  three  days  and  discharged  cured. 

When  one  reads  such  statements  as  these  in  the  first- 
class  medical  journals  it  makes  him  wonder  whether  the 
days  of  miracles  have  really  returned.  In  the  writer's 
experience  the  cure  of  morphine  addiction  in  a  few  days' 
time  is  like  learning  "German  in  ten  lessons."  Patients 
who  are  given  such  a  course  of  treatment  and  discharged 
cured  at  the  end  of  a  few  days'  time  find  that  they  have 
about  as  much  to  contend  with  after  their  cure  as  before 
it,  just  as  the  would-be  German  scholar  finds  that  after 
his  ten  lessons  he  has  very  much  more  to  learn  than  he 
thought  he  had  at  the  beginning. 

It  is  evident  that  the  word  "cure"  as  used  by  these 
gentlemen  does  not  mean  what  it  is  ordinarily  under- 
stood to  mean.  There  is  much  more  involved  in  the  cure 
of  a  case  of  morphinism  than  can  be  done  in  a  few  days' 
time  with  any  course  of  treatment,  however  perfect  it 
may  be. 

In  addition  to  the  drug  intoxication  of  which  the 
patient  is  suffering  the  system  is  surcharged  with  poison, 
both  of  intestinal  and  auto-  origin.  The  functional 


Unwarranted  Use  of  the  Word  "Cure."  179 

activity  of  all  the  excretory,  secretory,  and  digestive 
organs  is  impaired;  the  blood-changes  are  marked,  the 
red  corpuscles  are  greatly  diminished,  and  the  white 
correspondingly  increased.  The  patient  is  profoundly 
anemic;  muscles  flabby  and  relaxed;  nervous  system 
disordered;  mental  activity  impaired;  in  fact,  the 
patient  is  greatly  below  par  in  every  respect. 

In  the  treatment  of  this  or  any  other  disease  it  is  still 
necessary  to  conform  to  the  established  physiological 
laws  rather  than  to  depend  upon  some  miraculous  agent 
to  transform  our  patients  from  disease  to  health.  These 
markedly  deranged  conditions  cannot  be  corrected  in  a 
few  days'  time  to  such  a  degree  as  to  justify  the  patient 
being  discharged  "cured." 

The  administration  of  65  %  co-grain  doses  of  hyo- 
scine  in  two  and  one-half  days,  a  little  over  Yioo  grain 
every  hour,  is  excessive  medication  and  would  be  danger- 
ous in  many  cases.  The  author  does  not  wish  to  be 
understood  as  condemning  the  use  of  hyoscine  (scopo- 
lamine)  in  the  treatment  of  these  addictions,  because  it  is 
a  remedy  of  great  value;  but  it  has  its  limitations,  as 
well  as  its  use. 

It  does  not  cure  the  morphine  addiction,  as  is  claimed 
by  some  who  advocate  its  use  with  the  rashness  of  a  new 
convert.  But  it  does  fill  one  of  the  most  important  indi- 
cations in  the  treatment  of  such  cases.  If  the  withdrawal 
of  the  opiate  were  all  that  is  involved  in  the  cure  of  these 
addictions,  hyoscine  (scopolamine)  might  be  regarded 
as  a  cure,  but  that  is  not  all. 

The  physician  deceives  himself  if  he  thinks  that 
merely  because  the  opiate  has  been  withdrawn  by  the  aid 
of  hyoscine  and  the  patient  has  reached  the  stage  where 
the  administration  of  either  drug  is  not  longer  imperative 
that  he  is  cured.  He  is  still  very  weak  and  nervous ;  his 


180  Narcotic  Drug  Diseases  and  Allied  Ailments. 

system  is  still  in  a  toxic  condition,  not  as  much  so  as  at 
the  beginning,  but  still  sufficiently  so  to  cause  an  eleva- 
tion of  temperature  of  from  i°  to  3°,  attended  by  aching 
of  the  limbs  and  back,  excessive  nervous  reflexes,  and 
various  other  unpleasant  symptoms,  and  unless  he  has 
had  something  more  than  hyoscine  given  him  in  the  cure 
of  his  addiction  he  will  soon  have  a  diarrhea  that  will 
tax  his  endurance  to  the  limit,  if  it  does  not  force  his 
return  to  the  use  of  the  opiate. 

There  are  several  institutions  in  this  country  which 
depend  upon  hyoscine  to  cure  their  patients.  They  make 
the  most  wonderful  claims  for  the  drug,  or,  rather,  for 
their  particular  combination,  which  is,  in  fact,  nothing 
more  nor  less  than  hyoscine  or  one  of  the  drugs  of  that 
group.  They  regard  the  withdrawal  of  the  opiate  as  all 
that  is  involved  in  the  cure  of  these  addictions  and  insist 
upon  discharging  their  patients  within  eight  days  from 
the  beginning  of  the  treatment.  In  almost  every  instance 
such  patients  find  that  they  have  so  many  complications 
to  contend  with,  and  are  so  poorly  prepared  to  make  such 
a  fight,  that  they  soon  give  up  in  despair  and  return  to 
the  use  of  the  opiate.  Many  cases  with  such  a  history 
have  come  under  the  author's  care. 

In  the  very  best  hands  all  that  can  be  done  for  a 
patient  of  this  class  during  the  first  week  of  treatment 
is  to  clear  his  system  to  a  large  extent  from  the  retained 
excrementitious  matter  and  thus  remove  the  source  of 
intestinal  intoxication,  partially  cleanse  the  system  from 
ptomaine  and  other  poisons  of  auto-origin,  withdraw 
the  opiate,  and  bring  the  patient  to  a  condition  where  its 
use  is  no  longer  a  necessity.  When  this  is  done  the 
patient  is  not  cured,  but  he  has  only  reached  the  point 
where  convalescence  may  set  in.  Such  a  patient  needs 
medical  supervision,  discipline,  and  moral  support  as 


Time  Required  for  Cure.  181 

badly  during  the  period  of  convalescence  as  he  needed 
active  treatment  before  that  stage  was  reached. 

Fortunately  such  patients  convalesce  rapidly.  They 
eat  heartily,  digest  and  assimilate  a  large  quantity 
of  food,  and  take  on  strength  rapidly.  If  a  wise  super- 
vision is  exercised  over  them  and  they  are  required  to 
carry  out  a  physiological  course  of  physical  training,  so 
as  to  develop  all  the  newly  acquired  flesh  into  stout  mus- 
cular fiber  and  tone  up  what  they  already  have,  in  many 
instances  convalescence  may  be  advanced  to  a  wonderful 
degree  in  the  first  thirty  days.  In  thirty  to  sixty  days 
more,  with  proper  training,  such  a  patient  should  be 
practically  normal. 

When  such  a  physical  condition  has  been  reached, 
with  the  corresponding  improvement  in  the  mental  con- 
dition, and  the  patient  has  been  ofif  of  his  drug  and  all 
substitutes  for  it  for  a  period  of  thirty  to  sixty  days,  he 
may  be  discharged  as  cured.  The  word  "cure"  with 
reference  to  these  cases  should  not  be  used  to  mean  less 
than  that. 

Some  physicians  who  treat  these  cases  by  reduction 
insist  upon  a  period  of  treatment  and  personal  super- 
vision of  from  six  to  twelve  months.  The  author  thinks 
such  a  protracted  course  of  treatment  is  as  much  an 
extreme  in  the  other  direction  as  the  few  days'  term  is 
with  those  who  have  been  above  considered.  In  the  cure 
of  these  addictions  it  is  not  only  necessary  to  take  the 
patient  off  of  the  drug  and  put  him  in  good  physical  con- 
dition, but  if  he  is  to  be  permanently  cured  he  must  be 
made  independent  of  all  drugs. 

During  a  long  course  of  treatment,  supervision, 
and  at  least  partial  restraint,  the  patient  does  not  develop 
independence  or  self-reliance,  but  continues  to  depend 
upon  his  physician  and  upon  the  remedies  he  is  taking. 


182  Narcotic  Drug  Diseases  and  Allied  Ailments. 

His  volition  is  restricted  and  his  own  will  is  not  the  con- 
trolling force  from  which  his  conduct  springs.  In  fact, 
a  protracted  course  of  treatment,  supervision,  and  re- 
straint in  patients  of  this  class  who  are  already  slaves  to 
a  drug  tends  to  perpetuate  a  condition  of  invalidism  and 
dependence  from  which  the  patient  seems  powerless  to 
extricate  himself. 

In  the  experience  of  the  author,  patients  of  this  class 
who  have  been  taken  off  of  the  drug  by  the  proper 
method  and  have  been  developed  into  good  physical  con- 
dition as  rapidly  as  it  may  be  done  are  in  safer  condition 
to  be  thrown  on  their  own  resources  by  the  end  of  the 
eighth  to  tenth  week  after  the  drug  is  withdrawn  than 
they  are  if  kept  under  treatment  and  restraint  longer. 

At  this  period,  time  has  not  materially  obliterated 
the  memory  of  their  former  abject  slavery:  they  are 
supremely  happy  in  the  realization  of  their  freedom  and 
in  contemplating  the  desirable  things  life  may  have  in 
store  for  them,  since  they  have  another  chance,  another 
opportunity,  to  enter  upon  their  acquisition.  They  are 
full  of  hope,  buoyancy,  and  ambition.  The  world  and 
all  that  is  in  it  present  to  them  a  new  and  bright  prospect. 
At  this  flood  tide  of  hope  they  are  in  a  better  condition 
to  be  thrown  on  their  own  resources  and  to  establish 
themselves  securely  in  a  safe  relationship  to  all  things 
that  might  tempt  them  than  they  are  if  kept  under  re- 
striction until  this  tide  has  materially  ebbed. 

To  those  who  are  seeking  the  truth  in  this  matter  the 
author  would  say :  "Do  not  accept  the  miraculous  claims 
of  the  three-day-cure  men  on  one  hand;  neither  swing 
to  the  standard  of  those  who  insist  upon  the  period  of 
from  six  to  twelve  months'  treatment  and  restraint." 
There  is  a  middle  ground,  a  reasonable  position  where 
the  truth  may  be  found.  Remember  that  miracles  are 


Prolonged  Restraint  Damaging,  183 

not  to  be  expected,  and  that  restraint  does  not  develop 
self-reliance,  upon  which  the  patient  must  finally  depend 
and  without  which  man  is  mere  driftwood. 

It  will  be  interesting  to  consider  some  of  the  objec- 
tions raised  to  the  use  of  hyoscine  by  those  who  are 
opposed  to  it.  During  the  first  two  years  after  the  ap- 
pearance of  the  author's  first  paper  advocating  the  use 
of  hyoscine  in  the  treatment  of  drug  addictions  several 
articles  appeared  in  medical  literature,  magnifying  the 
dangers  of  the  use  of  that  remedy. 

In  the  Medical  News  of  Oct.  18,  1902,  Crothers  and 
Mattson  each  published  a  letter  in  which  they  condemned 
the  use  of  hyoscine  in  the  treatment  of  morphinism. 
Mattson  denounced  the  drug  in  strong  terms,  but  did  not 
give  specific  data  upon  which  his  opinion  was  based.  He 
seems  to  be  so  wedded  to  his  idol,  his  sedation-substitu- 
tion method,  that  he  cannot  look  upon  any  other  method 
with  even  the  slightest  degree  of  tolerance. 

This  is  unfortunate,  because  one  who  has  devoted  the 
time  to  the  study  and  treatment  of  these  addictions  that 
Mattson  has,  and  who  has  the  broad  charity  for  these 
unfortunate  victims  that  his  writings  show  him  to  pos- 
sess, should  have  a  more  successful  treatment  for  them 
than  the  one  he  advocates.  He  still  pursues  the  same 
method  he  has  advocated  for  many  years,  and,  while 
these  have  doubtless  given  good  results  in  his  hands,  this 
has  been  largely  because  of  his  skill  in  administering  it 
and  his  tact  in  managing  this  class  of  patient.  The  re- 
sults obtained  with  the  Mattson  method  in  the  hands  of 
others  have  not  been  satisfactory,  and,  judging  from  the 
expressions  of  standard  authors,  the  world  is  still  with- 
out an  acceptable  treatment  for  morphinism,  notwith- 
standing the  fact  that  the  Mattson  method  has  been 
before  the  profession  for  a  number  of  years 


184  Narcotic  Drug  Diseases  and  Allied  Ailments. 

Crothers  undertakes  to  give  a  specific  statement  of 
his  experience  with  the  use  of  hyoscine  in  a  dozen  or 
more  cases,  but  he  is  extremely  unhappy  in  that  effort. 
He  is  quite  non-specific.  He  says :  "In  each  case  delir- 
ium and  hallucination  and  delusions  of  a  mild  type  began 
after  the  second  or  third  dose  of  the  drug  was  given  and 
continued  for  from  two  to  four  weeks." 

Now,  are  we  to  understand  that  the  administration 
of  hyoscine  was  continued  during  these  two  to  four 
weeks,  or  are  we  to  understand  that  only  two  or  three 
doses  of  hyoscine  were  given  to  each  patient,  and  that 
the  delirium,  etc.,  induced  by  these  doses  continued  from 
two  to  four  weeks?  If  the  former,  then  nothing  unusual 
has  happened,  as  no  one  familiar  with  the  effects  of  hyo- 
scine is  surprised  at  one  under  its  influence  having  mild 
delirium,  hallucinations,  etc. ;  but  if  the  latter  view  is 
to  be  taken,  that  is,  that  as  a  result  of  the  administration 
of  two  or  three  doses  of  hyoscine  in  each  of  a  series  of 
12  cases  a  delirium,  etc.,  was  induced  which  lasted  from 
two  to  four  weeks,  then  the  author  must  say  that 
Crothers  has  recorded  an  experience  that  no  other  man 
has  had,  or  is  likely  ever  to  have. 

That  the  delusions  and  hallucinations,  etc.,  should 
continue  as  long  as  the  administration  of  hyoscine  is 
continued,  or  at  least  until  complete  tolerance  for  that 
drug  is  acquired,  everyone  would  expect,  but  that  such 
symptoms  should  continue  for  from  two  to  four  weeks  as 
a  result  of  the  administration  of  two  or  three  doses  of 
that  drug  is  unreasonable.  The  effects  of  hyoscine  are 
very  little,  if  any,  more  lasting  than  those  of  other  nar- 
cotics. The  delusions,  etc.,  from  its  use  are  of  short 
duration. 

In  a  series  now  numbering  more  than  3000  cases  in 
which  the  author  has  used  this  remedy,  only  in  two  or 


Hyoscine  Not  Substitute  for  Morphine.  185 

three  cases  has  delirium  or  delusion  of  any  kind  been 
present  as  long  as  forty-eight  hours  after  the  last  dose. 
Probably  in  I  case  out  of  10  such  symptoms  continued 
twenty-four  hours  after  the  last  dose,  but  in  fully  90  per 
cent,  of  the  cases  the  mind  was  perfectly  clear  by  the 
twelfth  hour  or  earlier,  and  remained  so  thereafter.  In 
many  cases  the  delirium  subsides  by  the  fourth  or  sixth 
hour  after  the  last  dose. 
Crothers  further  says : — 

"As  a  substitute  for  morphine,  I  believe  it  [hyoscine]  to  be 
more  dangerous  and  uncertain  than  the  bromide  of  sodium.  From 
the  use  of  both  of  these  drugs  delirium  and  dementia  are  almost 
certain  to  follow." 

Again  do  we  find  him  unhappy  in  his  statements.  If 
he  means  that  delirium  and  dementia  may  follow  the 
prolonged  or  habitual  use  of  either  of  these  drugs,  then 
he  is  doubtless  correct.  But  if  he  means  that  dementia 
is  almost  certain  to  follow  or  is  at  all  likely  to  occur  as 
the  result  of  the  proper  therapeutic  employment  of  either 
of  these  agents  for  the  length  of  time  such  remedies  are 
needed  in  the  treatment  of  morphinism,  then  he  is  again 
wide  of  the  mark. 

Instead  of  causing  dementia,  each  of  these  remedies 
has  made  a  greater  reputation  in  the  treatment  of  in- 
sanity than  any  other  two  remedies  in  materia  medica. 
There  is  no  authentically  reported  case  in  which  the 
proper  remedial  use  of  either  hyoscine  or  the  bromide 
has  ever  caused  dementia  or  other  lasting  mental 
disorders. 

In  persons  who  have  been  taken  off  of  morphine  by 
the  methods  advocated  by  the  author,  that  is,  thorough 
elimination  of  all  toxic  and  effete  material  as  a  primary 
step,  then  the  control  of  the  acute  withdrawal  symptoms 


186  Narcotic  Drug  Diseases  and  Allied  Ailments. 

with  hyoscine,  the  perfect  recovery  of  all  the  mental  fac- 
ulties has  been  one  of  the  most  uniform  and  striking 
features.  The  physical  equilibrium  is  regained  at  a  won- 
derfully rapid  rate,  but  the  mental  improvement  is  still 
more  marked. 

The  perceptive  and  reasoning  faculties  are  bright  and 
unimpaired;  the  memory  is  completely  restored.  It  is 
the  universal  testimony  among  patients  treated  by  the 
author  that  they  recall  accurately  any  event  with  which 
they  have  been  familiar. 

Some  time  since,  a  patient  of  this  class,  a  classical 
scholar,  who  had  been  using  morphine  in  large  quantities 
for  fifteen  years  was  discharged  from  treatment.  He 
said  that  during  most  of  the  time  he  had  used  the  drug 
he  had  hardly  looked  at  a  book  and  certainly  had  not 
thought  of  memorizing  a  quotation  from  one.  The  re- 
vival of  his  memory  was  so  perfect  and  was  such  a 
delightful  experience  to  him  that  he  devoted  much  of  his 
time  to  entertaining  his  fellow-patients  with  long  recita- 
tions from  Shakespeare  and  other  classical  writers  which 
he  had  committed  to  memory  in  his  schoolboy  days  thirty 
years  before.  He  assured  the  author  that  during  the 
time  he  used  morphine  he  was  never  able  to  recall,  con- 
nectedly, any  of  these  selections,  but  after  completing 
the  treatment  he  had  the  ability  to  recall,  with  perfect 
accuracy,  any  selection  he  had  thoroughly  memorized 
or  event  with  which  he  had  been  familiar. 

Another  patient  having  a  similar  experience,  a  lady 
who  had  used  morphine  five  years.  Within  a  few  days 
after  the  completion  of  her  treatment  she  sat  down  to  a 
piano  and  reproduced  from  memory  difficult  pieces  of 
music  which  she  said  she  had  not  played,  or  even  thought 
of,  for  several  years. 

In  the  experience  of  the  author,  instead  of  hyoscine 
being  dangerous  to  the  mind  of  the  patient,  it  does  more 


Effects  of  Hyoscine  on  Mind.  187 

to  awaken  and  revivify  the  mental  faculties  than  any 
other  remedy  with  which  the  author  is  acquainted.  It 
certainly  does  not  deserve  to  be  brushed  aside  as  treach- 
erous, unfit  for  use,  and  almost  certain  to  be  followed  by 
dementia  and  death.  Hyoscine  cannot  be  considered  a 
substitute  for  morphine,  and  there  is  no  reason  for  seek- 
ing" such  a  substitute. 

Hyoscine  is  unfit  for  prolonged  use,  but  with  proper 
discretion  and  with  proper  doses  it  can  be  used  as  safely 
as  any  other  narcotic.  It  is  certainly  not  more  dangerous 
than  atropine,  strychnine,  cocaine,  and  other  powerful 
agents  in  common  use.  To  be  safe  it  must  be  used  with 
the  same  discretion  and  forethought  that  is  necessary  to 
make  the  use  of  these  remedies  safe. 

Hyoscyamus  (henbane)  has  been  in  common  use  for 
centuries.  Its  alkaloids,  hyoscine  and  hyoscyamine, 
which  are  now  more  often  used,  do  not  produce  any 
effect  not  common  to  the  crude  drugs.  Yet  in  all  these 
years  no  one  else  has  recorded  such  results  from  their 
use  as  Crothers  does. 

It  is  well  known  that  mild  delirium  and  hallucination, 
both  of  sight  and  hearing,  are  the  usual  effects  of  full 
and  repeated  doses  of  hyoscine  or  any  other  of  the  bella- 
donna series  of  remedies,  and,  as  these  delusions  and 
hallucinations  are  the  direct  effects  of  these  preparations, 
it  is  to  be  expected  that  they  will  continue  as  long  as  the 
drug  is  given.  It  is  doubtless  true  that,  if  the  patient  be 
kept  constantly  under  the  influence  of  hyoscine,  or  any 
of  this  series  of  remedies,  for  a  period  long  enough  for 
the  localized  hyperemia  of  the  brain  which  they  induce 
to  cause  structural  changes  in  the  brain,  then  prolonged 
delirium,  or  even  permanent  dementia,  may  result. 

But  it  is  the  universally  recorded  experience  of  physi- 
cians who  have  made  extensive  use  of  these  remedies 


188  Narcotic  Drug  Diseases  and  Allied  Ailments. 

that  if  the  administration  is  continued  for  a  limited 
period  these  mental  symptoms  subside  in  a  short  time 
after  the  drug  is  discontinued  and  no  harm  results;  in 
fact,  no  after-effects  whatever  remain. 

Certainly  if  such  untoward  effects  as  Crothers  refers 
to  ever  followed  the  proper  therapeutic  employment  of 
these  drugs  someone  would  have  placed  the  fact  on  record 
before  this  time,  but,  as  no  such  record  can  be  found,  it 
is  the  belief  of  the  author  that  Crothers  has  overesti- 
mated the  effects  of  hyoscine  in  his  cases  and  under- 
estimated the  effects  of  the  toxic  matter  in  the  system  of 
the  patient,  as  well  as  the  effects  of  the  sudden  with- 
drawal of  the  opiate. 

The  prolonged  use  of  morphine  locks  up  in  the 
patient's  system  such  a  quantity  of  excrementitious  and 
toxic  matter  that  the  abrupt  withdrawal  of  morphine 
without  first  removing  such  toxic  matter  will  often  be 
followed  by  delirium,  hallucinations,  and  delusions,  and 
even  by  permanent  dementia,  without  the  administration 
of  hyoscine  or  any  other  drug.  The  doctor  does  not 
claim  to  have  in  any  way  prepared  his  patients  for  the 
withdrawal  of  the  opiate,  but  simply  to  have  discontinued 
morphine  and  begun  the  administration  of  hyoscine. 
Unsatisfactory  results  are  to  be  expected  from  such  a 
course  of  treatment,  especially  if  the  administration  of 
hyoscine  be  continued  for  a  considerable  length  of  time, 
as  it  evidently  was  in  these  cases. 

It  can  be  readily  demonstrated  that  the  suffering,  as 
well  as  the  mental  aberrations,  incident  to  the  withdrawal 
of  morphine  is  due  more  to  the  effects  of  the  toxic  matter 
with  which  the  system  of  the  patient  is  surcharged  than 
to  the  withdrawal  of  the  opiate  per  se. 

Upon  the  withdrawal  of  morphine  from  patients  in 
this  condition  the  nervous  system  wakes  up  to  the  pres- 


Small  Doses  of  Hyoscine  Sufficient.  189 

ence  of  this  irritating  toxic  matter  and  sets  up  an  active 
effort  to  throw  it  out,  and  in  this  it  goes  to  such  an  extent 
that  it  does  violence  to  its  own  integrity. 

The  prominent  feature  of  this  activity  is  a  rise  of 
temperature  of  from  I  °  to  4°.  This  fever  has  very  much 
the  type  of  a  "break-bone  fever."  One  suffering  from  it 
feels  as  if  every  bone  in  his  body  will  burst  and  that  every 
nerve  in  his  body  is  on  the  outside  and  is  being  lacerated 
by  some  torturing  instrument,  and  in  many  other  ways 
his  sufferings  are  unbearable. 

The  administration  of  more  morphine  under  these 
circumstances  will  allay  this  activity  of  the  system,  the 
temperature  of  the  patient  will  fall,  and  his  condition 
become  one  of  comfort.  The  administration  of  hyoscine 
at  this  time  does  not  reduce  the  fever,  but  at  first  rather 
increases  it;  therefore,  in  order  to  relieve  the  patient's 
discomfort,  very  much  larger  doses  of  hyoscine  must  be 
given  than  would  be  required  to  bring  relief  were  the 
fever  not  present.  In  fact,  relief  does  not  come  from  the 
effects  of  hyoscine  under  such  circumstances  until  delir- 
ium ensues,  and  then  the  patient,  being  unconscious,  does 
not  suffer. 

On  the  other  hand,  if  the  system  of  the  patient  be 
cleansed  of  toxic  matter  before  the  morphine  is  with- 
drawn the  fever  and  other  violent  reactionary  symptoms 
do  not  occur  to  such  a  degree  and  the  quantity  of  hyo- 
scine that  is  necessary  to  keep  him  in  perfect  comfort  is 
so  greatly  reduced  that  he  can  be  taken  through  the 
entire  course  of  treatment,  in  many  instances,  without 
the  occurrence  of  delirium.  In  other  cases  in  which 
slight  delirium  does  occur  it  subsides  within  a  few  hours 
after  the  administration  of  hyoscine  is  discontinued,  leav- 
ing no  untoward  after-effects. 

Another  influence  which  increases  the  tendency  to 
delirium  in  cases  when  morphine  is  withdrawn  without 


190  Narcotic  Drug  Diseases  and  Allied  Ailments. 

proper  preparatory  treatment  is  engorgement  of  the 
portal  system,  which  always  exists  in  such  cases.  When 
the  flow  of  the  blood  through  the  portal  system  is  thus 
obstructed  any  arterial  stimulant  expends  its  main  force 
upon  the  cerebral  circulation,  and,  therefore,  causes  a 
much  greater  degree  of  cerebral  blood-pressure  than  it 
would  were  the  portal  system  free  from  obstruction  and 
in  a  condition  to  receive  its  full  quota  of  the  blood-cur- 
rent. The  quantity  of  hyoscine  that  would  excite  an 
active  and  prolonged  delirium  under  such  circumstances 
can  be  given  to  the  patient  after  his  system  is  prepared 
for  it  without  the  occurrence  of  delirium  at  all,  but  if 
delirium  does  occur  it  will  be  of  transient  duration. 

In  Crothers's  cases  the  abrupt  withdrawal  of  mor- 
phine without  treatment  of  any  kind  would  likely  have 
been  followed  by  an  active  delirium  in  a  majority  of  the 
cases  and  probably  in  some  by  dementia.  Therefore,  in 
the  opinion  of  the  author,  the  untoward  symptoms  re- 
corded by  Crothers  can  be  fully  accounted  for  without 
attributing  them  to  hyoscine,  and  the  author  feels  that 
the  doctor  is  unwarranted  in  attributing  them  to  the 
proper  remedial  use  of  that  remedy. 

The  attitude  of  the  profession  toward  the  victims 
of  narcotic  drugs  is  not  at  all  commendable,  or  even 
reasonable.  Little  effort  has  been  made  by  members  of 
the  regular  profession  to  relieve  them,  and  this  has  left 
them  almost  entirely  to  the  hands  of  charlatans  and 
nostrum  venders,  from  whom  satisfactory  results  in  the 
treatment  of  any  disease  was  not  to  be  expected. 

Until  very  recently  the  few  reputable  men  who  have 
endeavored  to  restore  them  to  health  have  followed  such 
faulty  teachings  that  their  results  have  been  almost  as 
disappointing  as  those  of  the  irregulars. 

Notwithstanding  that  it  is  well  known  that  the  with- 
drawal of  the  drug  is  always  followed  by  suffering  of  the 


Is  Morphinism  a  Vice?  191 

most  intense  character,  and  even  by  dementia  or  death, 
men  of  high  standing  in  the  profession  who  write  medical 
books  and  whose  teachings  are  supposed  to  be  worthy  of 
credence  still  continue  to  speak  of  the  morphine  addiction 
as  a  mere  appetite,  a  vice,  a  habit,  and  to  maintain  that 
the  principal  indication  in  the  treatment  is  the  with- 
drawal of  the  drug. 

"The  indulgence  of  morphine  is  a  vice  of  recent 
years."  (Osier's  "Modern  Medicine.") 

"Morphinism  is  an  irresistible  craving  for  mor- 
phine." (Tyson's  "Practice,"  ed.  1906.) 

"When  the  disease  is  fully  developed  there  exists  an 
irresistible  craving  for  the  drug,  and  it  is  this  artificial 
appetite  that  is  the  chief  difficulty  to  be  overcome  in 
the  treatment.  It  is  the  craving  for  unnatural  stimulants 
that  must  be  fought.  If  this  craving  is  overcome  all  the 
rest  is  comparatively  easy."  ("American  Textbook  of 
Applied  Therapeutics,"  Wilson.) 

"The  withdrawal  of  the  poison  is  the  main  indica- 
tion." (Gordon's  "Diseases  of  the  Nervous  System,"  ed. 
1908.) 

"Mental  and  moral  attributes  are  anesthetized  by 
morphine  and  patient  lies  by  choice."  (Edward's  "Prac- 
tice of  Med.") 

"Morphinism — unconquerable  longing  for  mor- 
phine." ( Strumpell's  "Practice  of  Med/') 

These  men,  and  many  others  who  have  assumed  to 
speak  on  this  subject,  have  evidently  written  of  this  con- 
dition at  "long  range"  and  merely  continue  to  repeat 
the  statements  of  some  former  writer  who  also  drew  his 
conclusions  from  other  sources  than  actual  clinical  ex- 
perience. 

The  man  who  is  addicted  to  a  narcotic  drug  is  as 
truly  a  diseased  man  as  one  who  has  typhoid  fever  or 


192  Narcotic  Drug  Diseases  and  Allied  Ailments. 

pneumonia.  The  necessity  for  therapeutic  measures  is 
as  great  and  the  indications  for  their  employment  are  as 
positive  in  the  one  as  in  the  other.  Why  these  important 
measures  are  totally  ignored  by  leading  modern  writers 
is  beyond  comprehension. 

It  is  difficult  to  determine  from  a  careful  search  of  the 
literature  who  first  advanced  the  views  expressed  by  the 
authors  above  quoted.  It  is  evident  that  such  conclusions 
could  not  have  been  reached  from  personal  study  of  the 
subject.  In  the  opinion  of  the  author  those  who  have 
brought  down  to  date  and  given  the  weight  of  their 
authority  to  teachings  which  they  have  not  verified  by 
actual  clinical  experience  are  especially  blameworthy. 
No  author  is  justified  in  merely  parrot-like  repetition, 
and  thus  lending  the  weight  of  his  authority  to  the  teach- 
ings of  a  former  age.  If  he  has  verified  them  by  his  own 
clinical  experience,  then  he  is  justified  in  repeating  them 
and  passing  them  on  to  be  followed  by  his  devotees. 

But  it  is  not  believed  that  any  practical  experimenta- 
tion toward  the  end  of  truth  has  been  followed  by  these 
writers  when  speaking  of  drug  addiction.  If  they  were 
equally  erroneous  on  other  lines  of  teachings  the  profes- 
sion would  promptly  discard  their  works  altogether,  but 
the  fact  that  they  do  teach  sound  doctrine  on  so  many 
subjects,  and  that  they  are  followed  with  safety  by  the 
profession  along  these  lines,  gives  them  such  influence 
that,  when  they  do  teach  an  error,  it  is  fraught  with  the 
most  far-reaching  consequences. 

The  author  is  free  to  confess  that  before  he  cured  his 
first  case  of  drug  addiction  he  found  it  necessary  to 
entirely  discard  the  teachings  of  the  professions  up  to 
that  time.  Not  one  line  was  found  in  medical  literature 
on  this  subject  that  contributed  in  any  way  to  success  in 
the  treatment  of  such  a  case ;  in  fact,  when  the  teachings 


Entire  Control  of  Patient  Essential.  193 

of  the  authorities  were  followed  they  led  away  from 
rather  than  toward  a  cure.  Therefore,  disregarding  all 
former  teachings,  he  undertook  an  independent  study  of 
the  subject,  and  he  reached  the  conclusions  recorded  in 
this  work  solely  from  his  own  clinical  experience. 

The  first  practical  statement  of  the  real  pathology  of 
drug  addiction,  together  with  the  first  rational  basis  for 
its  treatment  founded  upon  the  general  principles  of 
medicine,  found  its  way  into  medical  literature  in  the 
paper  of  the  author  of  October,  1901.  No  intimation 
was  found  in  medical  literature  prior  to  that  time  of 
the  value  or  essential  necessity  of  elimination  as  a  pre- 
liminary step  in  the  treatment,  except  a  part  of  one  para- 
graph in  an  article  by  Waugh.  This  was  in  effect  that 
"calomel  is  beneficial  in  these  cases."  This  article,  how- 
ever, had  not  been  seen  by  the  author  until  after  the 
publication  of  his  first  paper ;  therefore,  his  conclusions, 
then  announced,  were  based  entirely  upon  his  own  clini- 
cal experience. 

Among  the  accessories  which  contribute  to  success  in 
the  treatment  of  narcotic  addiction,  none  has  so  much 
importance  as  a  well-equipped  institution  in  which  the 
patient  must  reside  during  the  period  of  treatment  and 
convalescence.  Control  of  the  patient  in  every  detail  is 
essential  to  success.  This  must  not  be  the  control  of 
coercion,  but  of  confidence;  the  control  a  medical  man 
exercises  over  his  patients  by  reason  of  the  unswerving 
confidence  of  that  patient  in  him. 

This  must  be  based  upon  the  fact  that  the  physician 
himself  is  really  in  earnest  in  his  efforts  to  cure  the 
patient  and  has  an  abiding  interest  in  the  welfare  of  the 
patient.  This  relation  of  mutual  trust  and  mutual  confi- 
dence is  absolutely  essential  to  success.  This  mutual 
confidence  cannot  exist  so  long  as  either  party  holds  the 
other  to  be  untrustworthy. 


13 


194  Narcotic  Drug  Diseases  and  Allied  Ailments. 

Any  physician  who  regards  narcotic  addiction  as  a 
mere  vice,  ^  perversion,  and  holds  all  addictees  to  be 
liars,  fiends,  perverts,  degenerates,  etc.,  is  unfit  to  treat 
such  a  patient.  The  very  fact  of  holding  such  opinions 
places  a  barrier  between  him  and  his  patient  that  makes 
the  establishment  of  confidential  relations  impossible. 

The  fact  that  the  patient  needs  to  place  himself  under 
the  care  and  control  of  a  physician,  and  that  he  will  not 
for  a  time  be  able  to  be  guided  by  his  own  volition  in  the 
matter  of  taking  or  not  taking  his  drug,  is  not  an  im- 
peachment of  his  moral  character.  He  seeks  the  aid  of  a 
physician  because  he  realizes  his  own  inability  to  control 
himself  with  reference  to  this  particular  matter,  and, 
unless  the  physician  can  credit  him  with  honesty  of  pur- 
pose and  with  being  worthy  of  confidence,  at  least  on 
other  matters,  he  should  not  undertake  his  case. 

A  resident  physician,  one  who  can  be  at  hand  at  all 
hours,  day  or  night,  to  administer  to  the  needs  of  the 
patients,  is  essential,  not  that  those  needs  will  come  so 
often,  but  when  they  do  come  they  must  be  met  promptly. 
These  patients  do  not  bear  to  be  put  off,  and  to  have  to 
wait  until  the  physician  can  come  from  a  distance  to 
relieve  them. 

It  must  be  remembered  that  their  experience  has  led 
them  to  lose  confidence  in  all  remedies  except  the  one 
remedy  they  have  been  taking,  and  now  that  that  is  to  be 
given  up  they  are  skeptical  as  to  the  power  of  other 
remedies  to  relieve  any  acute  distress  which  might  over- 
take them.  Under  these  circumstances  the  personal  con- 
fidence they  have  in  the  physician  is  a  wonderful  help  to 
them  and  with  him  present,  if  this  confidence  is  mutual, 
he  can  with  mild  and  harmless  remedies  relieve  any  dis- 
tress which  may  come  to  them,  and  thus  conduct  them 
safely  through  their  convalescence  and  do  much  to  re- 
store their  confidence  in  such  remedies. 


Advantages  of  Institutional  Treatment.  195 

In  a  well-equipped  institution  many  measures  are  at 
hand  which  are  of  the  greatest  value  in  treatment  of 
these  cases.  Hydropathy,  electricity,  massage,  physical 
training,  and  other  such  measures  should  be  used  in  the 
most  liberal  manner.  Hydropathic  treatment,  especially, 
is  of  great  value  in  the  days  following  the  withdrawal  of 
the  drug. 

Nothing  soothes  the  patient  more  completely  and  is 
more  likely  to  contribute  to  his  comfort  and  well-being 
than  a  neutral  bath,  especially  if  this  be  given  at  bed- 
time. This  will  often  aid  materially  in  securing  a  good 
night's  rest  and  in  restoring  the  nervous  system  of 
the  patient.  The  vapor  bath  is  valuable  in  some  cases, 
but,  as  drug  patients  are  usually  anemic,  they  do  not 
stand  the  vapor  bath  well. 

A  cold  pack  may  often  be  used  to  advantage.  Its 
antipyretic  effect  is  usually  sufficient  to  reduce  the  fever 
which  is  present  for  several  days  after  the  patient  is 
taken  off  the  drug.  A  half-hour  or  an  hour's  sweating 
in  the  pack  relaxes  the  tension  of  the  nervous  system  and 
is  often  followed  by  two  or  three  hours  of  quiet,  restful 
sleep,  which  refreshes  the  patient  very  much. 

It  is  a  mistake  for  any  physician  to  attempt  to  treat 
narcotic  drug  patients  at  their  homes  or  in  the  wards  of  a 
general  hospital.  Under  such  surroundings  failure  is 
more  likely  than  success. 

During  the  period  of  treatment  and  for  ten  days  or 
two  weeks  thereafter,  at  least  until  considerable  self- 
reliance  has  been  acquired,  the  patient  should  be  sepa- 
rated from  his  family,  and  from  all  others  to  whom  he 
looks  for  sympathy.  Sympathy  and  overattention  tend 
to  the  development  of  hysterical  symptoms  that  are 
troublesome  and  retard  the  acquirement  of  self-reliance 
which  is  so  essential  to  success  in  these  cases. 


1%  Narcotic  Drug  Diseases  and  Allied  Ailments. 

The  presence  of  the  physician  under  whose  care  the 
addiction  was  formed  or  who  has  attended  the  patient 
during  any  effort  at  treatment  that  has  ended  in  failure 
also  exerts  a  very  unwholesome  influence  over  the 
patient.  Patients  of  this  class  have  a  fixed  habit  of  de- 
pendence upon  some  extraneous  influence,  their  drug,  the 
sympathy  of  friends,  etc.,  and  have  largely  lost  their 
individuality. 

Therefore,  a  course  of  treatment  to  give  the  best 
results  must  be  disciplinary,  as  well  as  therapeutic.  It 
should  not  be  undertaken  in  the  home  of  the  patient, 
because  the  physician  cannot  have  such  control  of  him 
and  his  surroundings  as  is  essential  to  success.  This 
control  must  be  complete  during  the  early  part  of  con- 
valescence, as  well  as  during  the  treatment,  and  the 
physician  must  know,  beyond  peradventure,  that  he  has 
no  access  to  his  drug  or  any  substitute  for  it. 

Under  this  plan  of  treatment  the  therapeutic  meas- 
ures necessary  are  soon  completed,  but  the  end  sought  is 
not  merely  to  take  the  patient  off  of  his  drug  and  place 
him  where  his  physical  condition  will  not  require  its  use, 
but,  in  addition,  to  so  fortify  him  mentally  and  morally 
that  he  will  not  return  to  the  use  of  the  drug  from  sheer 
force  of  habit  or  otherwise. 

The  psychological  element  is  an  important  one  and 
should  be  intelligently  considered  and  skillfully  managed. 
The  fixed  habit  of  dependence  upon  a  drug  is  to  be  sup- 
planted by  a  counterhabit  of  independence  and  self- 
reliance,  and  both  time  and  discipline  are  essential  factors 
in  that  process.  This  is  one  of  the  chief  reasons  why  no 
tonic  or  after-  treatment  should  be  given. 

So  long  as  the  patient  takes  anything  his  mind  clings 
tenaciously  to  the  idea  that  his  well-being  depends  upon 
his  receiving  some  support,  some  outside  assistance,  and 


After-treatment — Not  Medication.  197 

he  is  thus  led  away  from,  rather  than  toward,  self- 
dependence. 

No  patient  of  this  class,  under  any  treatment,  is 
secure  from  relapse  if  he  is  discharged  taking  plain 
water,  if  he  thinks  it  is  medicine.  A  protracted  course 
of  treatment  tends  to  perpetuate  the  habit  of  invalidism 
and  defeats  the  very  object  sought  in  the  treatment. 
The  patient  must  be  taught  to  rely  entirely  upon  his  own 
resources  and  fully  convinced  of  his  ability  to  do  so. 

He  must  not  only  be  cured  of  the  addiction,  but  thor- 
oughly fortified  against  relapse.  This  can  certainly  be 
done,  but  the  time  required  varies  with  different  indi- 
viduals. Some  will  more  completely  regain  their  mental 
and  moral  equilibrium  in  a  few  weeks'  time  than  others 
will  in  several  months,  but  until  this  has  been  attained, 
at  least  to  a  fair  degree,  the  patient  should  not  be  dis- 
charged. 

Association  with  other  convalescent  patients,  the 
comradeship  thus  established,  and  the  encouragement  the 
patient  receives  from  witnessing  the  successful  recovery 
of  others  will  be  found  helpful  in  establishing  the  patient 
in  his  new  position.  Nothing  less  than  the  complete  and 
permanent  emancipation  of  every  patient  treated  should 
satisfy  us.  It  should  be  borne  in  mind  that  the  use  of 
opiates  does  not  cause  structural  changes  in  the  brain  or 
other  tissues  of  the  body,  but  that  the  derangements  due 
to  their  use  are  purely  functional  and,  therefore,  are 
certainly  and  permanently  curable. 

During  the  period  of  convalescence  the  patient  should 
live  as  much  as  possible  out  of  doors.  He  should  be 
encouraged  to  walk,  play  pool,  billiards,  basketball,  or 
tennis,  or  any  outdoor  game.  The  exercise  incident  to 
the  playing  of  these  games  keeps  the  skin  active,  keeps 
the  general  muscular  system  in  better  condition,  and 


198  Narcotic  Drug  Diseases  and  Allied  Ailments. 

converts  a  part  of  the  newly  acquired  flesh  into  stout 
muscular  fiber  instead  of  allowing  it  to  accumulate  as 
fat.  The  course  of  physical  training  that  the  author 
employs  has  proven  very  helpful  in  his  hands.  This 
course  will  be  given  in  detail  in  a  later  chapter  of  this 
work. 

Every  institution  should  have  as  a  part  of  its  equip- 
ment a  well-trained  masseur.  Massage  is  one  of  the 
accessories  of  treatment  which  is  often  of  the  very  great- 
est service.  A  good  general  massage  often  relieves  pain 
in  the  legs  and  back  or  other  parts  of  the  body  and 
enables  the  patient  to  secure  several  hours'  quiet,  restful 
sleep. 

Sleep  secured  from  drugs  is  not  so  refreshing  as 
normal  sleep  and  the  patient  feels  the  depressing  effects 
of  the  drug  on  the  following  day,  whereas  the  sleep 
induced  by  a  neutral  bath  or  a  good  massage  is  practi- 
cally natural  sleep  and  is  not  followed  by  depression. 
These  accessories  are  of  the  greatest  value ;  in  fact,  they 
cannot  be  overestimated. 

Every  means  that  is  rational  and  which  does  not  in- 
volve the  administration  of  drugs  should  be  used  to  make 
the  patient's  convalescence  comfortable  and  successful. 
Medicines  do  not  often  aid  materially ;  in  fact,  medicines 
should  not  be  given,  unless  there  is  a  specific  indication 
for  their  use. 

The  patient  is  to  be  thoroughly  weaned  from  the 
medicine-taking  habit,  not  one  drug  substituted  for 
another.  Therefore,  all  the  physical  means  and  all  the 
rational  physiological  measures  that  can  be  used  as  acces- 
sories should  be  brought  into  play.  These  do  not  make 
a  damaging  impression  on  the  patient  such  as  the  ad- 
ministration of  drugs  does,  and,  therefore,  should  be 
employed  to  the  exclusion  of  drugs  in  every  case  when 
they  can  be  made  to  serve  the  purpose. 


CHAPTER  IX. 

TREATMENT  (CONTINUED). 


REMEDIES  EMPLOYED. 
SPARTEINE  SULPHATE. 

IN  carrying  out  the  rapid  or  immediate  withdrawal 
of  opiates  from  those  addicted  to  their  use  some  reliable 
agent  for  the  support  of  the  heart  is  often  essential. 
Sparteine  sulphate  has  served  this  purpose  in  the  hands 
of  the  author  better  than  any  other  agent  in  the  entire 
materia  medica.  It  is  unfortunate  that  this  valuable 
remedy  should  not  be  better  known  to  the  profession,  and 
especially  that  its  dosage  should  be  so  misunderstood. 

In  looking  up  the  literature  on  this  subject  the  author 
has  found  the  widest  difference  of  opinion  existing 
among  men  of  equal  standing  and  who  are  doubtless 
equally  accurate  in  their  observation  of  the  effects  of 
remedies.  The  difference,  however,  in  their  statements 
as  to  the  effects  of  this  remedy  is  accounted  for,  in  the 
author's  judgment,  by  the  difference  in  their  views  as 
to  the  proper  dose  of  the  remedy. 

The  misunderstanding  as  to  the  size  of  the  dose  is 
doubtless  the  reason  this  remedy  is  not  now  in  general 
use.  Most  authors  give  its  dose  as  from  %  to  %  grain. 
The  U.  S.  Pharmacopoeia,  last  edition,  stated  a  dose  to 
be  %  grain,  but  the  hypodermic  tablet  makers  have  not, 
until  recently,  made  a  tablet  larger  than  Vio  grain  and 
few  of  them  have  listed  a  tablet  larger  than  %0  grain. 
These  are  the  quantities  in  which  it  has  usually  been 
tried,  but  many  practical  men  after  making  a  trial  of  it 

(199) 


200  Narcotic  Drug  Diseases  and  Allied  Ailments. 

in  these  quantities,  being  unable  to  develop  the  desired 
effects,  have  thrown  it  aside  as  of  no  value ;  while  had  the 
proper  dose  been  given,  the  results  would  have  been 
otherwise.  The  fault  was  not  with  the  remedy,  but  with 
the  size  of  the  dose. 

Bartholow  and  Ringer  are  the  only  authors  whose 
writings  the  author  has  examined  who  state  the  dose  at 
anything  like  the  proper  quantity.  They  put  the  dose 
at  from  %  to  2  grains.  One  and  one-half  to  2  grains 
would  be  more  nearly  correct;  in  fact,  2  grains  by  the 
stomach  are  as  small  a  dose  as  can  be  depended  upon. 
One  and  one-half  grains,  hypodermically,  is  a  fairly 
effective  dose,  but  there  is  no  reason  why  the  hypodermic 
dose  should  not  be  2  grains  also. 

It  is  a  non-toxic  drug  when  administered  in  an}' 
reasonable  quantity.  It  is  certain  and  definite  in  its 
effect  and,  in  the  author's  experience,  it  above  all  other 
remedies  deserves  to  be  classed  as  a  heart  tonic,  a  heart 
regulator.  It  does  just  what  we  want  done  when  we 
administer  a  heart  tonic  without  doing  those  things 
which  we  do  not  want  done. 

It  combines  the  desirable  effects  of  the  digitalis  and 
veratrum  without  their  undesirable  effects.  Since  physi- 
cians are  so  familiar  with  these  remedies,  the  author  will 
compare  the  effects  of  sparteine  with  those  of  these  two 
drugs. 

Digitalis  is  a  true  heart  tonic  so  far  as  its  effect  on 
the  heart  muscle  itself  is  concerned,  but,  while  it  adds 
tone  to  that  organ,  lessens  the  frequency  and  increases 
the  force  of  its  action,  it  also  powerfully  contracts  the 
entire  arterial  capillary  system  and  greatly  raises  blood- 
pressure,  thus  increasing  the  resistance  to  the  onward 
flow  of  the  blood-current.  So  marked  is  this  effect  that 
it  is  probable  that  it  adds  to  the  work  of  the  heart  as 


Sparteine,  Digitalis,  and  Veratrum  Compound.          201 

much  as  it  increases  its  strength;  therefore,  as  a  heart 
tonic  it  is  almost  useless. 

Veratrum,  on  the  other  hand,  reduces  the  force  and 
frequency  of  the  heart's  action  and  at  the  same  time 
dilates  the  arterial  capillaries,  thus  reducing  blood-pres- 
sure and  opening  up  the  way  for  the  onward  flow  of  the 
blood-current,  but  this  action  is  attended  by  great  de- 
pression, nausea,  and  other  undesirable  effects.  If  we 
could  develop  the  effects  of  digitalis  on  the  heart  muscle 
accompanied  by  the  effects  of  veratrum  on  the  arterial 
system  without  any  of  the  other  effects  of  these  two 
remedies  we  would  have  an  ideal  heart  tonic.  In  spar- 
teine  we  have  a  remedy  that  does  that  very  thing. 

It  adds  to  the  tone  of  the  heart  muscle  as  greatly  as 
does  digitalis ;  it  also  reduces  the  frequency  and  increases 
the  force  of  the  heart  action,  but,  instead  of  contracting 
the  arterial  capillaries  and  raising  blood-pressure,  as 
digitalis  does,  it  has  directly  the  opposite  effects.  While 
it  does  not  dilate  the  arterial  capillaries  so  greatly  as 
veratrum  does,  it  does  so  to  a  marked  degree,  but  with- 
out any  of  the  unpleasant  effects  peculiar  to  that  drug. 

Especially  marked  are  its  effects  upon  the  arterial 
capillaries ;  in  this  respect  it  resembles  belladonna ;  how- 
ever, its  effects  are  not  confined  to  the  superficial  capil- 
laries, but  extend  to  the  deeper  capillaries  as  well. 
Under  its  influence  the  pulse  is  soft,  full,  and  compress- 
ible, instead  of  hard  and  unyielding  as  from  digitalis. 

It  is  prompt  in  action.  Its  effects  are  well  established 
within  an  hour;  in  fact,  if  given  hypodermically,  the 
effects  are  quite  noticeable  within  half  an  hour  or  less, 
being  in  that  respect  very  unlike  digitalis,  but  in  point 
of  duration  of  effect  it  is  again  like  digitalis,  the  effects 
lasting  from  six  to  twelve  hours.  In  fact,  it  has  almost 
the  promptness  of  strychnine,  with  the  sustained  action 
of  digitalis. 


202  Narcotic  Drug  Diseases  and  Allied  Ailments. 

In  the  matter  of  correcting  irregularities  of  the  heart 
action  it  should  be  given  first  place.  It  corrects  these 
with  great  promptness,  and  the  sustained  effect  of  the 
drug  makes  its  frequent  administration  unnecessary.  An 
initial  dose  of  2  grains  should  be  given  and  it  should  be 
repeated  in  two  to  three  hours.  After  that  it  need  not  be 
administered  oftener  than  every  four  to  six  hours. 

Sparteine  is  a  true  and  reliable  heart  tonic,  an  excel- 
lent non-irritating  diuretic,  and  is  entirely  free  from 
untoward  or  objectionable  effects;  it  lessens  the  fre- 
quency and  increases  the  force  of  the  heart  action,  but 
does  not  raise  blood-pressure.  This  is  made  possible  by 
the  fact  that  it  is  also  a  vasodilator  and  by  this  phase  of 
its  action  it  dilates  the  arterial  capillaries  to  such  a 
degree  as  to  enable  the  arterial  system  to  receive  and 
accommodate  the  increased  volume  of  blood  propelled  by 
the  more  vigorous  action  of  the  heart  without  increasing 
arterial  tension. 

It  adds  tone  to  the  heart  muscle  and  causes  it  to 
propel  a  larger  volume  of  blood  at  each  impulse,  and  by 
its  vasodilator  action  it  opens  up  the  way  for  the  passage 
of  this  increased  volume  of  blood,  thus  increasing  the 
propelling  force  and  lessening  the  resistance.  This 
makes  it  the  ideal  heart  tonic,  and  in  the  experience  of 
the  author  it  is  the  only  remedy  or  combination  of  reme- 
dies which  meets  this  indication  perfectly.  It  is  also 
taken  up  readily  from  the  stomach.  The  effect  on  the 
stomach  is  that  of  a  bitter  tonic.  It  has  no  tendency  to 
cause  nausea  or  other  unpleasant  symptoms. 

There  has  been  quite  a  conflict  in  the  statement  of 
writers  as  to  the  effect  of  sparteine  on  the  blood-pressure. 
Some  say  that  it  raises  blood-pressure;  others,  that  it 
decreases  blood-pressure.  This  is  quite  in  accord  with 
their  statement  as  to  its  general  effects.  In  the  literature 


Sparteine,  a  Reliable  Heart  Tonic.  203 

of  the  subject  the  author  has  found  that  those  who  have 
given  sparteine  in  doses  of  2.  grains  have  been  uniformly 
pleased  with  its  effect  and  have  given  it  the  highest 
praise,  both  as  a  heart  tonic  and  a  diuretic;  but  on  the 
other  hand,  those  who  have  used  the  drug  in  fractional- 
grain  doses  have  condemned  it  as  inert  or  of  little  value 
and  have  made  conflicting  statements  with  reference  to 
its  effects  on  blood-pressure. 

The  author  has  recently  made  a  careful  study  of  this 
particular  effect  of  the  drug  and  is  able  to  present  here- 
with instrumental  tests  showing  a  uniform,  but  slight 
decrease  of  blood-pressure  in  every  case  where  as  much 
as  2.  grains  of  the  drug  were  given. 

The  fall  of  blood-pressure  begins  within  an  hour  irom 
the  time  of  giving  a  dose  and  reaches  its  minimum  about 
the  end  of  the  sixth  hour,  and  this  reduced  pressure  con- 
tinues for  four  to  six  hours  after  the  minimum  is 
reached.  A  uniform  fall  of  from  10  to  15  mm.  Hg  has 
been  noted  in  every  case  thus  far  observed  by  the 
author  and  in  no  case  has  there  been  the  slightest  degree 
of  rise  of  blood:pressure. 

The  effect  on  the  pulse  was  noticeable  earlier  than 
the  instrument  would  show  the  change  in  blood-pressure. 
A  pulse  which  is  small  and  deficient  in  volume  fills  out  to 
a  well-rounded  pulse  in  from  thirty  to  sixty  minutes  after 
the  administration  of  the  full  dose  of  sparteine  and  this 
effect  is  sustained  for  several  hours.  It  begins  to  wane 
by  the  end  of  the  fifth  or  sixth  hour,  but  the  blood-pres- 
sure does  not  begin  to  rise  for  several  hours  afterward. 
The  accompanying  sphygmographic  tracings  show  the 
effect  on  the  heart  in  the  matter  of  regulating  its  action. 

In  this  connection  the  author  wishes  to  call  attention 
to  an  element  in  the  action  of  sparteine  not  heretofore 
noted,  that  is,  that,  while  the  usual  or  ordinary  effect  of 


204          Narcotic  Drug  Diseases  and  Allied  Ailments. 

the  remedy  is  to  slow  the  heart  action,  in  certain  condi- 
tions it  increases  the  rate.  The  sphygmographic  tracings 
and  pulse  records  in  the  first  three  cases  which  follow 
illustrate  this  phase  of  its  action  as  well  as  its  effect  as  a 
heart  tonic. 

In  the  first  2  cases  there  was  irregular  heart  action, 
the  irregularity  consisting  of  an  extra  prolonged  diastole 
occurring  at  regular,  but  frequent  intervals  as  if  the 
heart  muscle  was  tired  and  was  seeking  to  rest  for  a 
fraction  of  time  longer  than  normal,  and  then  regular 
contractions  would  occur  again,  to  be  followed,  in  turn, 
by  a  prolonged  diastole. 

Two  grains  of  sparteine  were  given,  and,  this  having 
imparted  a  reliable  degree  of  tone  to  the  heart  muscle, 
the  time  formerly  occupied  by  the  prolonged  diastole  was 
filled  with  regular  contractions  and  this  resulted  in  in- 
creased pulse  rate  as  well  as  regular  and  uniform  action. 
This  increase  in  one  case  was  4  and  in  the  other  6 
beats  per  minute. 

In  the  third  case  there  was  very  slow  and  sluggish 
heart  action,  conveying  the  impression  of  a  tired  heart, 
one  that  not  only  needed  rest,  but  was  seeking  to  take  it. 
Sparteine  in  this  case  imparted  power  and  tone  to  the 
heart  muscle,  filled  out  the  volume  of  the  pulse,  and  in- 
creased the  rate  from  52  to  74. 

The  author  has  repeatedly  observed  this  effect  from 
sparteine  and  now  does  not  hesitate  to  say  that  sparteine 
has  the  power  to  regulate  action  of  the  heart,  but  that  in 
doing  so  it  always  tends  to  restore  its  action  to  the 
normal  or  in  the  direction  of  the  normal,  both  in  rate  and 
volume.  It  imparts  a  degree  of  muscular  tone,  which 
enables  the  heart  to  act  more  normally,  and  therefore  it 
deserves  to  be  classed  as  a  true  heart  tonic. 


Sparteine  Reduces  Blood-pressure.  205 

Tracing  No.  I  shows  patient  with  a  regularly  irreg- 
ular heart  action,  the  irregularity  being  one  full  long 
contraction  with  two  intervening  shorter  contractions, 
followed  regularly  by  one  long  and  two  short  beats. 
Pulse  rate,  70;  blood-pressure,  125. 


Tracing  No.  i. 

Tracing  No.  2  is  from  same  patient  two  hours  later 
and  two  hours  after  2  grains  of  sparteine  had  been  given 
by  mouth. 

At  the  time  of  taking  this  tracing  the  pulse  rate  was 
74,  an  increase  of  four  beats  to  the  minute,  but  the  blood- 
pressure  had  fallen  to  120.  It  will  be  noticed  that  the 
heart  action  had  become  perfectly  regular  and  the  longer 


Tracing  No.  2. 

upward  stroke  of  the  needle  shows  increased  volume  of 
pulse.  Tracing  No.  3  was  taken  seven  hours  later,  and 
this  shows  a  distinct  waning  in  the  effects  of  the  remedy 
as  indicated  by  shorter  upward  stroke  of  the  sphygmo- 
graphic  needle. 

The  pulse  rate  at  the  time  of  taking  tracing  No.  3 
was  76;  blood-pressure,  115.  While  the  volume  of  the 
pulse  had  decreased  considerably  at  the  time  of  taking 


206  Narcotic  Drug  Diseases  and  Allied  Ailments. 

tracing  No.  3,  the  irregularity  shown  in  tracing  No.  I 
did  not  show ;  in  fact,  this  irregularity  did  not  recur  to 
such  a  degree  as  to  be  noticeable  until  twelve  hours  from 


Tracing  No.  3. 


the  time  of  taking  tracing  No.  I,  or  fourteen  hours  from 
the  time  of  giving  the  single  2-grain  dose  of  sparteine. 
Tracing  No.  4  is  from  a  similar  case  in  which  there 


Tracing  No.  4. 

was  a  regularly  irregular  pulse,  the  irregularity  consist- 
ing of  one  long  and  five  intervening  shorter  beats.  The 
pulse  was  full  and  strong,  but  regularly  irregular. 


Tracing  No.  5. 

One  and  one-half  hours  after  2  grains  of  sparteine 
had  been  given  hypodermically  tracing  No.  5  was  taken. 
At  the  time  of  taking  tracing  No.  4  the  blood-pressure 
was  130;  pulse  rate,  68.  At  time  of  taking  tracing  No. 
5  the  blood-pressure  was  120;  pulse  rate,  74. 


Sparteine  Regulates  Heart  Action. 


207 


It  will  be  noticed  that  in  each  of  these  cases  the  effects 
of  sparteine  in  correcting  the  irregularity  increased  the 
pulse  rate  slightly.  This  is  directly  opposite  to  its  effects 
when  there  is  no  irregularity  to  correct.  Where  the 
heart  action  is  weak  and  the  muscle  lacking  in  tone,  it 
imparts  strength  and  tone,  but  decreases  the  rate;  this 
decrease  in  rate  is  usually  from  5  to  10  beats  per  minute, 
but  when  the  heart  action  is  very  rapid  and  weak  the 
decrease  in  rate  is  often  20  to  40  per  minute. 

When  the  heart  action  is  abnormally  slow  and  weak, 
sparteine  acts  as  a  regulator  both  of  the  volume  and 


Tracing  No.  6. 

frequency  of  heart  action.  In  such  cases  the  added 
muscular  tone  brings  the  heart  action  up  nearer  to  the 
normal,  even  if  that  be  to  increase  the  frequency  of  its 
contractions  as  well  as  increase  the  volume  of  blood  pro- 
pelled by  each  contraction.  This  is  shown  by  tracings  6 
and  7,  in  Case  III,  which  follows.  In  this  case  the  pulse 
was  abnormally  slow  and  thready,  the  rate  being  52  per 
minute;  blood-pressure,  125. 

Two  grains  of  sparteine  were  given  hypodermically 
and  in  thirty  minutes  distinct  improvement  in  the  volume 
of  the  pulse  could  be  detected.  Tracing  No.  7  was  taken 
two  hours  from  the  time  the  sparteine  was  given.  At  the 
time  of  taking  this  tracing  the  pulse  rate  had  increased 
to  74  and  the  blood-pressure  had  fallen  to  120.  The 
difference  in  the  tracing  indicates  the  improvement  in 
the  volume. 


208  Narcotic  Drug  Diseases  and  Allied  Ailments. 

Six  hours  after  tracing  No.  7  was  taken,  or  eight 
hours  from  the  time  the  sparteine  was  given,  tracing  No. 
8  was  taken.  At  this  time  the  effects  of  the  remedy 
had  been  partially  exhausted,  as  indicated  by  the  de- 
creased volume  of  the  pulse.  The  rate  had  also  become 
slower,  it  now  being  65  per  minute,  but  that  the  remedy 


Tracing  No.  7. 

was  still  exerting  considerable  influence  is  shown  by 
comparison  of  tracings  Nos.  6  and  8. 

While  the  author's  conclusions  as  to  the  physiological 
effects  and  therapeutic  use  of  sparteine  are  based  solely 
upon  his  own  clinical  study  of  the  remedy,  he  finds  that 


Tracing  No.  8. 

Oscar  Jennings,  of  Paris,  France,  had  preceded  him  in 
making  such  a  study.  The  conclusions  arrived  at  by  the 
author  and  Jennings,  each  acting  independently  of  and 
unknown  to  the  other,  harmonize  to  such  an  extent  and 
so  fully  sustain  each  other  that  the  author  takes  pleasure 
in  quoting  the  following  from  Jennings's  work : — 

"The  want  of  morphine  shows  itself  by  certain  symptoms 
which,  as  I  have  said,  are  natural  indications  of  the  treatment 
required.  It  should  be  borne  in  mind  that  when  giving  up  mor- 


Sparteine,  Duration  of  Effect. 


209 


phine  it  is  a  question  of  giving  up  not  an  habitual  sedative,  but 
principally  a  stimulant,  and  a  stimulant  of  such  transcendent 
power  that  the  vital  collapse  which  results  from  its  suppression 
far  exceeds  anything  that  could  result  from  the  privation  of  any 
other  stimulant. 

"By  gradual  reduction  and  change  from  the  more  stimulating 
hypodermic  to  the  sedative  rectal  injections,  the  collapse  that 
would  have  resulted  from  sudden  hypodermic  suppression  has 
been  avoided;  but  if  there  were  nothing  now  to  be  done  beyond 
progressive  reduction  of  the  morphine,  as  is  the  case  outside  of 
my  treatment,  the  final  suppression,  unless  spread  over  a  long 


Tracing  No.  9. — From  morphine  patient  in  state  of  want 

time,  would  still  give  rise  to  a  great  deal  of  discomfort.  Obser- 
vation, however,  shows  that  the  suppression  of  morphine,  which 
amounts  practically  to  the  suppression  of  a  fictitious  vital  force, 
gives  rise  to  general  functional  depressions  and  metabolic  per- 
versions, and  these  disturbances  serve  as  our  guide  to  treatment. 

"The  heart  is  nearly  always  affected  in  its  functions,  and 
the  sphygmographic  tracing  shows  a  sluggishness  that  is  only  too 
eloquent  as  regards  discomfort.  This  constitutes  my  first  thera- 
peutic indication. 

"The  above  tracing  (No.  9)  from  a  former  communication 
to  the  Academy  of  Medicine  shows  the  pulse  of  a  patient  who  is 
in  want  of  his  dose  of  morphine. 

"Tracings  10  and  n  are  practically  identical,  but,  while  the 
first  is  the  effect  of  a  dose  of  morphine,  the  second  shows  the 
effect  of  an  injection  of  sparteine. 

"Heart  tonics  form,  then,  my  first  means  of  preventing  the 
craving.  The  first  of  the  three  tracings  <=hows  a  peculiar  plateau 

14 


210  Narcotic  Drug  Diseases  and  Allied  Ailments. 

caused  by  the  want  of  cardiac  impulsion,  together  with  a  resist- 
ance to  the  passage  of  blood  in  the  vessels.  A  hypodermic  injec- 
tion given  at  this  time  re-establishes  the  normal  state  of  the 
circulation,  as  is  shown  in  the  second  tracing,  taken  from  the 
same  patient  as  the  first  at  an  interval  of  a  few  minutes.  It  was 
the  study  of  these  tracings  that  suggested  the  use  of  cardiac 


Tracing  No.  10. — From  same  patient  with  pulse  restored  by  morphine. 

tonics  and  stimulants  as  substitutes  for  the  morphine,  and,  in 
so  far  as  the  heart  is  concerned,  the  third  tracing  shows  how 
completely  they  can  replace  it. 

"As  is  the  case  for  each  of  the  means  of  treatment  I  have 
proposed,  the  utility  of  heart  tonics  has  been  endorsed  by  every 
subsequent  French  observer.  I  shall  content  myself  with  one 
quotation  only: — 


Tracing  No.  II. — From  same  patient,  showing  the  restoration  of  the 
pulse  after  a  state  of  want  by  injection  of  sparteine. 

'  'The  pulse  of  the  morphine  habitue,'  says  Pichon,*  'does 
not  afford  to  the  finger  any  important  indication  .  .  .  but  there 
is  a  registering  apparatus,  the  sphygmograph,  which  compensates 
for  this  insufficiency  as  regards  delicacy  of  touch,  and  which 
analyzes  the  slightest  arterial  anomalies.  It  is  in  this  manner 
that  the  experiments  to  which  we  refer,  and  which  we  had  the 

"  *  'Du  Morphinisme,'  Paris :    O.  Doin,  1890." 


Jennings' 's  Study  of  Sparteine.  211 

good  fortune  of  witnessing,  were  made.  .  .  .  These  researches 
were  made  by  O.  Jennings,  attached  to  the  laboratory  of  Professor 
Ball,  upon  the  numerous  morphine  habitues  who  were  attending 
the  clinic  at  the  time.  .  .  .  Before  arriving  at  a  definite  result, 
Jennings  took  a  series  of  tracings  from  patients  in  different  stages 
of  morphinism — state  of  want,  state  of  satisfaction,  intermediary 
condition,  normal  condition.'  Pichon  then  gives  the  conclusions 
of  the  communication  presented  by  Professor  Ball  and  myself 
at  the  Academy  of  Medicine,  and  adds:  'Nous  avons  controle 
a  plusieurs  reprises  ces  savantes  recherches.  Nous  avons  pris  un 
tres  grand  nombre  de  traces,  et  nous  sommes  arrive  aux  memes 
resultats.'  He  then  points  out  that  the  sphygmographic  examina- 
tion of  the  pulse  is,  as  I  have  always  taught,  the  best  way  of 
telling  whether  a  patient  is  honest  or  not  in  carrying  out  the 
prescribed  reduction.  If  the  plateau  is  not  obtained  when  the 
patient  ought  to  be  in  a  state  of  want,  there  need  be  no  hesitation 
— he  takes  morphine  secretly.  'This  discovery  has  been  the 
pivot,'  he  continues,  'of  the  physiological  treatment,  which  ap- 
pears to  have  given'  [as  we  shall  see  at  the  end  of  the  chapter] 
'very  good  results.'  'After  numerous  trials,  Jennings  found  that 
the  sphygmographic  tracings,  after  the  use  of  sparteine  and  trini- 
trine,  gave  the  same  results  as  an  injection  of  morphine.  The 
problem  was  solved  physiologically  and  clinically.  It  [the  treat- 
ment] often  gave  before  us  excellent  results.  .  .  .  Most  in- 
teresting practical  consequences  result  from  these  physiological 
discoveries,  both  as  regards  diagnosis  and  treatment.'  Further 
on,  after  passing  in  review  the  different  treatments  that  have 
been  advocated,  Pichon  concludes:  'We  should  prefer  the 
physiological  treatment  of  Jennings,  based  upon  the  action  of 
sparteine  and  trinitrine.  .  .  .  We  have  seen  that  these  two 
therapeutic  agents  replace  absolutely  the  circulatory  action  of 
the  morphine  euphoria,  and  overcome  the  state  of  want  by  causing 
the  disappearance  of  the  plateau.' 

"Further  on  he  confirms  the  value  of  sparteine  in  causing  the 
disappearance  of  discomforts  brought  about  by  depression  of 


212  Narcotic  Drug  Diseases  and  Allied  Ailments. 

the  heart.  'According  to  the  patients,'  he  says  (quoting  from  my 
communication  to  the  Academy  of  Sciences),  'this  medicine  gives 
them  heart.  The  indications  of  the  sphygmographic  tracings  show 
how  this  familiar  expression  is  rigorously  exact  from  the  point 
of  view  of  the  physiological  action  on  the  heart.  Sulphate  of 
sparteine  increases  the  contractile  energy  of  the  heart,  regularizes 
its  rhythm,  acts  with  great  rapidity,  and  possesses  a  considerable 
persistence  of  action.  These  are  properties  that  render  it  ex- 
tremely precious  in  the  period  of  abstinence,  and  make  it  a 
medecine  de  choix.' " 

While  sparteine  is  a  remedy  of  the  greatest  value  in 
the  treatment  of  drug  addiction,  as  well  as  in  all  other 
conditions  which  require  the  support  and  regulation  of 
the  heart  action,  it  is  in  pneumonia  that  it  fills  a  place 
that  no  other  remedy  or  combination  of  remedies  fills 
equally  as  well. 

In  that  disease  we  have  an  overworked  heart,  high 
blood-pressure,  pulmonary  and  general  venous  conges- 
tion, and  death  results  from  failure  of  oxidation  of  the 
blood  due  to  heart  exhaustion.  Sparteine  counteracts 
the  development  of  this  condition  more  perfectly  and 
does  more  to  correct  it  after  it  has  developed  than  any 
other  drug  with  which  the  author  is  acquainted. 

It  decreases  the  frequency  and  increases  the  force  of 
the  heart  action,  imparting  a  reliable  degree  of  tone  to 
the  heart  muscle.  At  the  same  time,  by  dilating  the 
arteries  and  reducing  blood-pressure,  it  relieves  the  heart 
of  its  burden,  thus  enabling  it  to  handle  the  volume  of 
blood  without  laboring  and  to  throw  an  ample  current 
to  the  lungs,  where  the  improved  capillary  circulation 
which  it  induces  promotes  abundant  oxidation. 

It  does  this  without  a  single  unpleasant,  undesirable, 
or  hurtful  effect.  In  fact,  the  only  other  effect  of  the 


Spartcine  in  Pneumonia.  213 

remedy  is  one  which  in  pneumonia  is  needed  almost  as 
badly  as  the  one  which  has  just  been  described.  Its 
power  to  improve  the  arterial  capillary  circulation 
renders  it  a  most  certain  and  efficient  non-irritating 
diuretic.  In  pneumonia,  as  well  as  in  drug  addiction,  its 
diuretic  effect  is  a  very  helpful  one. 

The  following  cases  will  illustrate  its  promptness, 
efficiency,  and  usefulness : — 

CASE  I. — I.  McF.,  admitted  Feb.  8,  1900.  In  coming 
from  home  he  traveled  a  part  of  the  way  overland 
through  a  drenching  rain  and  was  wet  and  shivering 
from  cold  when  admitted.  He  was  65  years  old  and  had 
used  gum  opium  by  mouth  habitually  for  twenty-seven 
years.  He  was  put  to  bed  after  a  hot  bath  and  soon 
became  comfortable.  That  evening  he  was  given  a  thor- 
ough eliminating  course  and  by  noon  the  next  day  his 
intestinal  canal  was  well  emptied,  and  so  far  as  could  be 
seen  at  that  time  there  was  no  ill  effect  from  his  ex- 
posure. The  opiate  was  then  withdrawn  and  the  patient 
was  kept  moderately  under  the  influence  of  hyoscine  for 
the  next  two  days,  during  which  time  calomel  in  small 
doses  was  given  to  stimulate  the  action  of  the  glandular 
system. 

On  the  fourth  day  of  treatment,  when  it  was  sought 
to  discontinue  all  narcotic  drugs,  the  patient  began  to 
show  signs  of  pneumonia  and  in  a  short  time  that  disease 
was  well  developed.  His  condition  was  recognized  as 
one  of  extreme  gravity  from  the  beginning,  because  of 
his  age  and  feebleness  and  of  the  long-standing  drug  ad- 
diction, as  well  as  because  of  the  large  area  of  the  lung 
involved.  The  temperature  ran  high  and  other  symp- 
toms were  of  corresponding  severity. 

The  author  had  been  accustomed  to  rely  upon  digi- 
talis, strychnine,  and  whisky  for  support  of  the  heart  in 


214  Narcotic  Drug  Diseases  and  Allied  Ailments. 

such  cases.  These  were  freely  administered,  and  the 
administration  of  an  opiate  was  resumed,  but,  notwith- 
standing every  effort  to  support  him,  by  the  fourth  day 
of  the  attack,  a  fatal  termination  within  twelve  to  twenty- 
four  hours  seemed  inevitable.  His  pulse  was  120  when 
reclining  quietly,  but  the  slight  exertion  of  raising  him 
to  a  sitting  posture  would  increase  the  rate  to  150. 
Respiration  was  40  and  labored;  face  livid;  in  fact, 
the  general  carbon-dioxide  poisoning  was  rapidly  de- 
veloping. 

The  author  had  had  some  experience  with  sparteine 
prior  to  that  time,  but  not  enough  to  gain  much  confi- 
dence in  it.  Still,  it  was  evident  that  other  remedies  were 
failing  and  it  was  decided  to  give  sparteine  a  trial.  Ac- 
cordingly, 2  grains  of  sparteine  sulphate  were  given 
hypodermically,  and  this  was  repeated  at  intervals  of  two 
hours.  At  the  time  of  giving  the  second  dose  a  distinct 
improvement  in  the  patient's  condition  could  be  seen  and 
within  six  hours  the  change  was  very  marked.  The 
pulse  had  come  down  to  90  per  minute  and  the  volume 
and  quality  were  very  much  improved ;  breathing,  30  per 
minute  and  much  less  labored.  Assuming  the  sitting 
posture  now  only  increased  the  pulse  rate  10  per  minute 
instead  of  30,  as  before. 

The  digitalis  and  strychnine  were  discontinued,  but 
no  other  change  was  made  in  the  general  line  of  treat- 
ment. By  the  end  of  the  first  twenty-four  hours  after 
beginning  the  sparteine  the  pulse  rate  was  70  and  from 
that  time  on  throughout  the  attack  the  pulse  was  held 
between  70  and  90  and  the  patient  made  an  uninter- 
rupted recovery.  Sparteine,  in  doses  of  2  grains,  was 
given  hypodermically  every  two  hours  for  the  first  six 
days  and  then  the  intervals  were  lengthened  to  four  and 
finally  to  six  hours.  Its  administration  was  kept  up  three 


Sparteine,  Effect  on  a  "Blue  Baby."  215 

weeks  altogether,  by  the  end  of  which  time  the  patient 
had  gained  sufficient  strength  not  to  require  support. 

After  the  administration  of  sparteine  was  begun  it 
was  depended  upon  entirely  for  control  and  support  of 
the  circulation  and  it  met  these  indications  more  per- 
fectly than  any  other  drug  had  ever  done  in  the  author's 
hands. 

This  experience  led  the  author  to  make  very  free  use 
of  this  agent  and  to  study  its  action  closely.  During  the 
twelve  years  intervening  since  this  experience,  the 
author  has  used  sparteine  most  freely  and  in  a  large  and 
varied  series  of  cases,  and  is  sure  that  it  has  enabled  him 
to  meet  successfully  many  extreme  conditions  which  he 
could  not  have  otherwise  met.  One  of  the  most  marked 
was  an  infant  of  six  weeks  in  which  there  was  failure  of 
closure  of  the  foramen  ovale.  This  little  patient  was 
under  the  care  of  Jordan  and  Goree,  of  Pine  Bluff,  Ark. 

CASE  II. — G.  E.  B.  At  birth  the  child  appeared  to 
be  entirely  normal,  but  at  six  weeks  of  age  it  began  to 
show  signs  of  venous  stasis,  bowels  became  torpid,  and 
as  the  portal  engorgement  increased  the  heart  action  was 
more  embarrassed  and  a  real  "blue  baby"  was  soon  the 
result. 

Physicians  were  called  and  the  treatment  begun. 
Calomel  and  other  evacuants  were  administered,  but 
without  favorable  results.  Strophanthus  and  nux 
vomica  were  given  in  sufficient  quantities  to  establish  the 
full  physiological  effects  of  these  remedies,  but  in  spite 
of  all  treatment  the  condition  of  the  patient  grew  worse. 
The  heart  action  became  more  rapid,  the  general  venous 
congestion  more  marked,  and  the  breathing  extremely 
embarrassed. 

The  author  saw  the  child  on  the  third  day  from  the 
development  of  the  more  marked  symptoms.  The  con- 


216  Narcotic  Drug  Diseases  and  Allied  Ailments. 

dition  of  the  patient  seemed  to  be  beyond  hope ;  the  pulse 
could  not  be  detected  at  the  wrist;  breathing,  90  per 
minute,  and  the  entire  body  was  as  blue  as  the  proverbial 
"turkey  gobbler's  snout."  It  did  not  seem  possible  for 
the  child  to  live  an  hour  longer. 

The  patient  was  in  the  hands  of  two  of  the  most 
competent  physicians  in  the  city  and  their  treatment 
was  in  accordance  with  the  teaching  of  the  best  authori- 
ties, but  no  improvement  had  been  made  in  the  condition 
of  the  little  patient  by  anything  which  had  been  given. 
These  physicians  extended  the  author  the  courtesy  of 
giving  whatever  he  thought  best,  but  there  seemed 
nothing  left  for  him  to  do  but  to  give  some  soothing 
potion  and  let  the  little  fellow  die  in  less  distress.  With 
that  idea  in  mind,  %o  grain  of  heroin  was  given.  At  the 
end  of  half  an  hour  the  child  was  still  alive,  but  more 
stupid.  Breathing  was  rapid,  but  was  attended  with  less 
effort  and  was  shallower. 

The  author  felt  that,  as  the  child  had  not  died  during 
this  half-hour,  it  would  be  wrong  to  sit  idly  by  and  do 
nothing,  so  he  decided  to  give  l/io  grain  of  sparteine 
sulphate.  This  was  done  and  in  thirty  minutes  signs  of 
improvement  were  detected.  Breathing  became  less 
labored  and  by  the  end  of  thirty  minutes  more  this  and 
other  signs  of  improvements  were  unmistakable.  Two 
hours  from  the  time  of  giving  the  first  dose  of  sparteine, 
l/2Q  grain  more  was  given.  At  this  time  the  respiration 
had  decreased  to  70  per  minute  and  the  pulse  could  be 
detected  at  the  wrist,  but  could  not  be  counted.  In  two 
hours  more,  or  four  hours  from  the  time  the  first  dose 
of  sparteine  was  given,  the  respiration  was  60,  pulse  150, 
and  could  be  counted  at  the  wrist.  The  deep  livid  hue 
had  given  way  to  a  bright  arterial  flush,  resembling 
somewhat  the  flush  from  belladonna.  The  child  nursed, 


Sparteine,  Source  of.  217 


and  fell  into  a  natural  sleep,  for  the  first  time  in  three 
days. 

The  improved  circulation  with  the  attendant  areation 
of  the  blood  soon  restored  the  nervous  system  to  its 
normal  responsiveness  and  then  the  purgatives,  which 
had  lain  dormant  in  the  system  for  two  or  three  days, 
began  to  act  and  continued  to  do  so  until  the  bowel  was 
well  emptied.  This,  of  course,  overcame  the  obstruction 
of  the  portal  system,  which  was  doubtless  the  cause  of 
the  original  attack,  and  the  child  was  practically  well 
within  twenty-four  hours. 

Sparteine  in  ^/Go-grain  doses  was  continued  for  a 
week  at  intervals  of  four  hours  and  then  the  periods 
between  the  doses  were  lengthened  to  six  hours  and  these 
were  kept  up  for  five  months,  at  which  time  they  were 
discontinued.  No  further  disturbance  of  the  circulation 
occurred  and  the  little  patient  is  now  a  strong,  healthy 
child. 

Sparteine  is  the  alkaloid  derived  from  Cysticus 
scoparius,  or  common  broom  corn.  The  sulphate  is  the 
only  salt  of  this  alkaloid  on  the  market,  and  it  is  doubt- 
less as  satisfactory  for  general  use  as  any  that  can  be 
made.  It  is  slightly  deliquescent,  but  if  kept  in  stop- 
pered bottles  it  maintains  its  dry,  crystalline  form.  This 
salt  is  readily  soluble  in  water  at  ordinary  temperatures 
and  may  be  administered  hypodermically,  by  mouth,  or 
by  rectum. 

In  studying  the  effects  of  any  drug  the  only  rational 
course  is  to  administer  that  drug  alone,  uncombined,  in 
such  doses  and  at  such  intervals  as  to  establish  its  full 
physiological  effects  in  the  system.  After  maintaining 
that  effect  for  a  reasonable  time,  if  the  therapeutic  im- 
pression or  remedial  effect  sought  to  be  made  has  not 
materialized,  then  one  has  reason  to  doubt  the  efficacy  of 


218  Narcotic  Drug  Diseases  and  Allied  Ailments. 

the  remedy.  Confirmation  of  such  experience  by  re- 
peated trial  would  justify  the  entire  rejection  of  the 
remedy,  but  until  such  a  study  of  its  effects  has  been 
made  no  therapeutic  agent  should  be  said  to  be  of  no 
value. 

Those  who  have  used  sparteine  according  to  this  rule 
hold  it  to  be  one  of  the  most  valuable  therapeutic  agents 
in  our  entire  list,  classing  it  along  with  such  remedies  as 
calomel,  quinine,  strychnine,  morphine,  etc.  Those 
writers  who  consider  it  of  little  value  place  the  dose  at 
%o  to  l/4  grain.  Such  doses  are  entirely  insufficient  and 
will  disappoint  anyone  who  may  depend  upon  them. 

The  writer  has  made  a  careful  study  of  this  remedy, 
having  used  it  in  doses  of  all  sizes  from  the  fractional 
grain  up  to  3  grains  given  at  intervals  of  two  hours.  It 
was  found,  however,  that  doses  of  2  grains  given  at 
intervals  of  from  three  to  six  hours  would  establish  and 
maintain  the  full  physiological  and  remedial  effects  of 
the  drug  upon  an  average  adult.  In  cases  where  the 
effect  of  the  remedy  is  urgently  needed  it  is  best  to  give 
2  grains  and  repeat  that  dose  at  the  end  of  two  hours ; 
then  the  dose  may  be  continued  at  intervals  of  three  to 
four  or  six  hours,  as  seem  indicated. 

It  is  a  reliable,  non-irritating  diuretic.  This  action 
occurs  whether  the  remedy  be  given  hypodermically,  by 
the  mouth,  or  by  the  rectum.  The  general  improve- 
ment it  induces  in  the  systemic  circulation,  especially  that 
of  the  arterial  capillary  circulation,  extending  to  the 
kidneys,  would  result  in  diuretic  action;  but  it  seems  to 
have  an  elective  action  for  the  kidney  circulation,  its 
diuretic  action  being  marked.  It  has  no  diaphoretic 
action. 

Sparteine  has  been  found  very  useful  in  postopera- 
tive suppression  of  urine.  In  discussing  the  paper 


Sparteine  in  Postoperative  Suppression.  219 

Montgomery  read  before  the  North  Carolina  State 
Medical  Association  at  Raleigh,  May,  1904,  the  author 
called  attention  to  sparteine  as  a  reliable,  non-irritating 
diuretic  which  could  be  administered  hypodermically. 
Stuart  McGuire  was  present  and  heard  the  discussion, 
and  from  that  he  began  the  use  of  sparteine  in  such 
cases  in  2-grain  doses.  As  a  result,  he  reports  in 
American  Journal  of  Surgery  of  February,  1907,  6 
cases  of  postoperative  suppression  which  he  feels  sure  he 
would  have  lost  under  his  former  management,  but 
which  were  saved  by  the  administration  of  sparteine. 
He  gives  the  entire  credit  for  recovery  of  these  cases  to 
sparteine. 

This  experience  has  brought  him  into  entire  accord 
with  the  statements  of  the  author  that  the  only  reason 
that  the  drug  is  not  in  common  use  is  because  it  has  been 
tried  in  doses  entirely  too  small  to  be  effective.  He  says : 
"To  get  results,  it  must  be  given  in  doses  of  I  to  2  grains, 
repeated  every  three  to  six  hours."  When  so  given,  he 
says  that  he  has  "repeatedly  seen  it  slow  a  runaway 
heart  and  set  in  motion  the  pair  of  stalled  kidneys." 

In  surgical  cases  sparteine  is  also  of  great  value  in 
preventing  shocks  and  postanesthetic  nausea.  Its  power 
to  sustain  the  heart  action  during  the  anesthesia  reduces 
shock  greatly,  if  it  does  not  entirely  prevent  it.  If  the 
shock  is  avoided,  postanesthetic  nausea  rarely  occurs, 
provided  the  intestinal  canal  has  been  properly  emptied 
before  the  anesthetic  was  given.  The  notes  of  2  cases 
which  follow  are  fairly  typical  of  the  series  of  40  con- 
secutive cases  in  which  the  author  prepared  the  patient 
for  operation,  in  none  of  which  nausea  followed  the 
anesthetic. 

CASE  III. — J.  B.  G.,  hip-joint  amputation.  Tubercular. 
Operation  by  Crisler. 


220  Narcotic  Drug  Diseases  and  Allied  Ailments. 

The  patient  was  prepared  for  operation  by  administration 
of  calomel,  10  grains;  extract  of  cascara,  10  grains;  ipecac,  i 
grain;  strychnine  nitrate,  %  grain;  atropine  sulphate,  %0  grain, 
made  into  four  capsules,  one  given  at  4,  6,  8,  and  10  P.M. 
on  an  empty  stomach,  followed  the  next  morning  by  3  ounces  of 
castor  oil.  Forty-eight  hours  later  a  course  of  the  same  strength 
was  given,  followed  the  next  morning  by  oil.  This  was  twenty- 
four  hours  before  the  operation.  The  patient  was  then  put  on  2 
grains  of  sparteine  every  three  hours  by  the  mouth  and  was  given 
liquid  nourishment  up  to  within  a  few  hours  of  the  time  of  the 
operation.  One  hour  before  the  time  of  the  operation  2,  grains 
of  sparteine  and  %  grain  morphine  with  }4oo  grain  hyoscine  were 
given  hypodermically. 

The  patient  went  on  the  operating  table  with  pulse  84.  Ether 
was  used  and  the  operation  lasted  one  and  one-quarter  hours. 
During  that  time  there  was  practically  no  variation  in  the  pulse 
rate  or  volume,  and  at  the  completion  of  the  operation  the  pulse 
rate  was  88,  full,  strong,  and  regular.  Just  before  the  close  of 
the  operation  2.  grains  of  sparteine  were  given  hypodermically, 
and  these  doses  were  kept  up  at  intervals  of  four  hours  for  several 
days;  the  patient  was  given  I  pint  of  saline  solution  by  rectum 
and  put  to  bed.  No  nausea  followed  and  shock  was  not  per- 
ceptible. Patient  was  allowed  water  up  to  the  time  of  operation 
and  was  given  hot  liquid  nourishment,  half-glass  five  hours  after 
operation,  and  this  was  repeated  every  two  to  three  hours  during 
the  following  day ;  then  other  nourishment  was  given. 

CASE  IV. — Cervix  and  gall-bladder.  Operation  by  Max 
Henning. 

Patient  prepared  for  operation  as  in  former  case  and  was 
given  sparteine,  2.  grains  by  mouth  every  four  hours  for  last 
twenty-four  hours  before  operation,  the  last  dose  coming  one 
hour  before  time  of  operation,  at  which  time  34  grain  of  morphine 
and  %oo  grain  of  hyoscine  were  given  hypodermically.  Ether 
was  the  anesthetic  employed.  Pulse  at  time  of  beginning  opera- 


Sparteine  in  Surgical  Practice.  221 

tion  was  84,  at  close  of  operation  90,  with  no  perceptible  change 
in  volume.  Shock  was  practically  nil.  Sparteine  was  continued 
at  intervals  of  four  hours,  I  pint  of  saline  by  rectum  as  soon  as 
patient  was  put  to  bed,  and  hot  water  to  drink  was  allowed  three 
hours  after  operation  and  from  that  time  on  was  given  as  freely 
as  the  patient  wished.  Buttermilk  was  given  nine  hours  after  the 
operation.  The  patient  was  not  nauseated  in  the  slightest  degree 
at  any  time. 

In  this  series  of  40  cases,  in  which  the  preliminary 
purgation  was  carried  out  with  the  same  degree  of  thor- 
oughness above  noted  and  the  patient  kept  under  the 
influence  of  sparteine  for  twenty-four  hours  before  the 
operation,  shock  has  been  hardly  perceptible  and  nausea 
has  not  occurred ;  whereas  with  the  same  care  in  prepa- 
ration of  the  patient  without  sparteine,  vomiting  oc- 
curred after  the  anesthetic  in  a  majority  of  the  cases ;  the 
pulse  rate  was  frequently  from  20  to  40  per  minute  more 
rapid  at  the  close  of  the  operation  than  at  the  beginning 
and  the  operation  was  attended  by  the  usual  degree  of 
shock. 

When  the  patient's  intestinal  canal  has  been  thor- 
oughly emptied  and  portal  engorgement  overcome  before 
the  operation,  and  the  patient  is  well  under  the  influ- 
ence of  sparteine  at  the  time  of  operation,  it  is  rare 
to  have  a  variation  of  more  than  10  beats  per  minute 
in  the  pulse  rate  during  a  prolonged  operation.  Shock 
is  much  reduced  and  nausea  rarely  occurs.  This  result 
cannot  be  expected  from  the  administration  of  sparteine 
in  emergency  work  where  there  is  no  time  for  cleansing 
the  patient's  system  of  toxic  matter;  neither  can  it  be 
expected  in  cases  where  a  saline  cathartic  alone  is  de- 
pended upon  to  empty  the  intestinal  canal,  but  even  in 
these  cases  sparteine  contributes  materially  to  the  safety 
and  comfort  of  the  patient. 


222  Narcotic  Drug  Diseases  and  Allied  Ailments. 

The  administration  of  sparteine  after  the  operation 
is  also  beneficial.  It  insures  a  more  uniform  and  effi- 
cient circulation,  especially  a  better  capillary  circulation, 
and  this  tends  to  promote  primary  union. 

This  reference  to  the  value  of  sparteine  in  surgical 
cases  is  given  here  because  it  is  frequently  found  neces- 
sary to  operate  on  those  who  have  been  recently  taken  off 
the  narcotic  drugs.  The  chronic  ailments  which  establish 
the  addiction  frequently  remain  and  must  be  cured  by  a 
surgical  operation  after  the  drug  is  withdrawn.  In 
these  cases,  when  nausea  and  vomiting  are  permitted  to 
occur  after  the  operation  it  is  extremely  difficult  to  re- 
frain from  giving  an  opiate  to  quiet  the  patient.  This  is 
not  admissible  in  those  who  have  been  recently  taken  off 
the  drug;  that  is  to  say,  if  it  is  found  necessary  to  give 
an  opiate  following  the  operation  they  soon  get  back  into 
dependence  upon  it,  thereby  making  another  treatment 
for  the  addiction  imperative. 

With  this  plan  of  management  of  the  cases  the  author 
has  been  able  to  have  his  patients  operated  on,  and  to 
conduct  them  through  the  convalescence  from  the  opera- 
tion without  re-forming  the  drug  addiction.  Whereas, 
when  they  have  been  called  upon  to  suffer  two  or  three 
days  intensely  from  postanesthetic  nausea,  he  has  not 
had  the  heart  to  deny  them  the  relief  an  opiate  would 
give  them,  even  if  it  did  make  an  additional  treatment 
for  the  addiction  necessary.  It  is  with  a  hope  that  these 
suggestions  may  be  helpful  to  others  who  have  to  contend 
hand  to  hand  with  these  conditions  that  they  are  here 
given. 

Sparteine  sulphate  sells  in  the  market  for  about 
70  cents  per  ounce  wholesale.  Merck's,  Mallinckrodt's, 
Squibb's,  and  Powers  &  Weightman's  preparations  have 
been  found  equally  reliable.  For  hypodermic  use  2 


Aids  in  Preventing  Postoperative  Nausea.  223 

grains  dissolved  in  20  minims  of  water  constitute  a 
solution  of  suitable  strength  for  use.  This  causes  pain 
when  injected  into  the  tissues,  but  in  many  thousand 
injections  the  writer  has  not  had  an  abscess  from  it. 
If  the  solution  is  injected  very  slowly  it  does  not  cause 
as  much  pain  as  it  does  when  the  full  dose  is  injected 
quickly.  For  stomach  administration  the  capsule  is  the 
most  convenient  vehicle.  A  No.  4  capsule  holds  prac- 
tically 2  grains  and  that  is  a  safe  and  efficient  dose. 

In  endeavoring  to  secure  some  salt  of  sparteine  which 
was  less  irritating  to  the  tissues  when  injected  hypoder- 
mically  the  author  secured  from  Merck  &  Co.  a  supply 
of  the  hydrochloride  of  sparteine.  This  salt  was  found 
to  be  very  deliquescent  and  difficult,  therefore,  to  pre- 
serve, but  after  giving  it  a  thorough  trial  the  author 
reached  the  conclusion  that  it  had  no  advantage  over 
the  sulphate.  When  a  solution  of  the  hydrochloride  of 
the  same  degree  of  concentration  was  used  it  proved  to 
be  equally  as  irritating  to  the  tissues  as  did  the  sulphate ; 
therefore,  its  use  was  given  up,  and  the  use  of  the  sul- 
phate resumed.  Sulphate  and  hydrochloride  are  the 
only  salts  of  this  drug  listed  by  the  manufacturing 
pharmacist  in  this  country,  and,  so  far  as  the  author  has 
been  able  to  learn,  these  are  the  only  salts  of  it  which  are 
made. 


CHAPTER  X. 

TREATMENT  (CONTINUED). 


REMEDIES   EMPLOYED. 
GELSEMININE. 

GELSEMININE  is  another  remedy  which  the  author 
has  found  particularly  useful  in  the  treatment  of  drug 
and  alcohol  addiction.  This  is  used  either  in  the  form 
of  specific  tincture  of  gelsemium  or  of  the  alkaloid 
gelseminine.  This  remedy  has  been  urged  as  of  great 
value  by  the  Eclectic  School  of  Medicine,  but,  as  physi- 
cians of  the  regular  school  of  medicine  are  the  true 
eclectics,  it  has  been  engrafted  upon  our  therapeutic  list. 

Gelsemium  is  a  motor  depressant  and  cerebral  seda- 
tive. It  also  has  mild  antipyretic  properties.  These 
properties  combined  make  it  a  reliable  nerve  sedative. 
In  cases  of  extreme  nervousness,  especially  attended 
with  pain  in  the  back,  or  with  pain  in  the  hollow  internal 
organs,  gelseminine  has  a  very  happy  effect. 

It  depresses  the  spinal  centers,  and  thus  decreases 
the  tendency  to  irregular  or  spasmodic  muscular  con- 
traction. In  neuralgia  or  myalgia  occurring  in  drug 
patients  during  the  first  week  or  so  of  convalescence,  this 
remedy  may  be  used  with  great  benefit.  It  has  no  harm- 
ful after-effect.  As  its  effects  are  established,  the  patient 
experiences  a  calm,  soothing  quietude,  which  is  fre- 
quently attended  by  restful  sleep. 

To  get  the  best  effects  from  gelseminine  it  should  be 
given  in  doses  of  ^5  grain,  repeated  at  intervals  of  two 
hours,  until  the  full  physiological  effects  of  the  remedy 
(224) 


Gelseminine  a  Cerebral  Sedative.  225 

are  manifest.  While  gelseminine  is  poisonous  if  given 
in  excessive  quantities,  it  can  be  pushed  until  its  full 
physiological  effects  are  established  without  the  slightest 
danger  of  toxicity.  Its  effects  on  the  eyelids  are  very 
marked,  causing  them  to  droop,  and  the  remedy  can 
safely  be  given  until  that  effect  is  clearly  noticeable. 
When  ptosis  is  developed,  the  dose  should  be  reduced. 
This  is  always  within  the  bounds  of  safety. 

PILOCARPINE. 

Pilocarpine  is  another  remedy  of  considerable  value 
in  drug  cases;  in  fact,  it  might  be  said  that  it  is  one 
of  great  value,  especially  during  the  period  of  con- 
valescence. 

A  number  of  writers  have  advocated  the  use  of  pilo- 
carpine  in  combination  with  hyoscine,  for  the  purpose 
of  overcoming  the  dryness  of  the  throat  and  mouth  from 
the  effects  of  that  remedy.  The  writer  has  made  careful 
tests  of  pilocarpine  for  this  purpose,  but  has  not  seen  any 
benefit  from  it.  It  is  true  that  it  does  overcome  the  dry- 
ness  of  the  mouth  and  throat  to  some  extent,  but  while 
doing  this  the  secretion  it  excites  from  the  mucous  mem- 
brane of  a  patient  under  the  influence  of  hyoscine  is  of 
a  tenacious,  sticky  type,  which  the  patient  finds  great 
difficulty  in  expectorating.  It  clings  to  the  lips  and  often 
requires  repeated  efforts  to  free  it  from  them.  This 
tenacious  secretion  is  much  more  disagreeable  than  the 
dry  throat  and  mouth  which  it  is  given  to  relieve. 

Therefore,  it  is  not  at  this  stage  of  the  treatment  that 
the  author  considers  the  remedy  of  any  value.  It  is 
useful,  however,  for  the  purpose  of  reducing  fever, 
which  these  patients  have  for  some  days  after  the  with- 
drawal. This  temperature,  running  from  l/2°  to  i1/^0, 
is  promptly  reduced  by  %  or  %0  grain  of  pilocarpine. 


15 


226  Narcotic  Drug  Diseases  and  Allied  Ailments. 

This  induces  gentle  diaphoresis,  and  usually  an  hour  or 
two  of  quiet  sleep.  This  sleep  is  not  followed  by  any 
unpleasant  or  hurtful  after-effect. 

While  pilocarpine  is  not  classed  as  hypnotic,  still  in 
these  cases,  when  there  is  a  temperature  of  %°  to  i/^0> 
a  hypodermic  of  pilocarpine  given  at  bedtime  promptly 
reduces  the  fever.  The  perspiration  incident  to  this 
remission  is  not  excessive,  but  the  general  relaxation  of 
the  system  which  accompanies  it  brings  on  a  state  of 
quietude  and  relaxation  which  induces  sleep.  This  sleep 
continues  sometimes  as  much  as  three  or  four  hours. 
It  is  not  really  a  drug  sleep,  but  a  sleep  from  deferves- 
cence induced  by  the  physiological  effects  of  the  remedy. 

A  serious  objection  to  the  repeated  administration 
of  pilocarpine  in  these  cases  arises  from  its  effect  on 
the  gastrointestinal  mucous  membrane.  If  this  remedy 
is  repeated  too  frequently,  for  several  days  in  succes- 
sion, it  induces  a  diarrhea  which  may  be  troublesome; 
therefore,  it  is  not  recommended  for  repeated  or  pro- 
longed use,  but  as  an  occasional  remedy,  especially  for 
a  dose  at  bedtime  for  a  few  nights.  Given  in  this  way, 
it  is  of  great  value.  It  should  not  be  given  soon  after  a 
meal,  since  if  the  stomach  is  full  it  is  likely  to  produce 
nausea. 

ASPIRIN. 

Aspirin  is  another  remedy  which  has  proven  of  con- 
siderable value  in  the  author's  hands.  It  is  a  reliable 
antipyretic  and  analgesic,  and  is  quite  free  from  hurtful 
after-effects.  In  fact,  what  after-effects  it  has  are  whole- 
some, being  antiseptic  in  character.  Aspirin  is  derived 
from  salicylic  acid  and  is  broken  up  in  the  intestinal  canal 
into  its  constituent  elements,  thus  liberating  salicylic 
acid  in  the  intestinal  canal,  and  this  is  a  valuable  anti- 
septic. 


PUocarpine,  Antipyretic  and  Hypnotic. 


Aspirin  is  much  more  reliable,  as  an  antipyretic,  in 
drug  cases  than  any  of  the  coal-tar  derivatives.  The 
coal-tar  derivatives  have  but  little  effect  on  the  tempera- 
ture which  follows  the  withdrawal  of  the  opiate,  but 
aspirin  in  full  doses  reduces  this  temperature  very 
promptly  and  in  a  most  satisfactory  manner.  Ten  grains 
is  usually  an  effective  dose. 

HYDROCHLORIC  ACID. 

In  many  drug  cases  the  author  has  found  deficient 
secretion  of  hydrochloric  acid  after  withdrawal  of  the 
drug.  The  earlier  writers  thought  there  was  an  excess 
of  hydrochloric  acid;  in  fact,  they  demonstrated  the 
presence  of  an  excess  of  hydrochloric  acid  during  the 
use  of  the  narcotic.  They  attributed  the  hyperacid  con- 
dition found  to  be  present  to  overproduction  of  hydro- 
chloric acid. 

But  this  hyperacidity  is  evidently  due  to  under- 
consumption of  acid  resulting  from  the  semiparalyzed 
condition  of  the  intestinal  canal  rather  than  to  over- 
production. The  canal  being  so  motionless  below  the 
stomach,  the  acid  secreted  in  the  stomach  is  not  passed 
downward  at  a  normal  rate,  and,  therefore,  cannot  be 
neutralized  by  the  alkaline  secretions  of  the  intestine, 
and  is,  therefore,  present  in  excessive  quantities. 

When  the  patient  is  taken  off  the  drug  by  the 
methods  herein  outlined,  this  excessive  acidity  is  not  at 
all  apparent;  in  fact,  there  is  more  often  a  deficient 
secretion  of  hydrochloric  acid  than  otherwise.  In  these 
cases  hydrochloric  acid  is  a  remedy  of  the  greatest 
value.  It  will  enable  the  patient  to  take  and  digest  a 
larger  quantity  of  nourishment.  It  is  antiseptic  and 
opposes  acetic,  butyric,  and  lactic  acid  fermentation,  and 
thereby  prevents  rather  than  causes  a  hyperacid  condi- 
tion of  the  stomach. 


228  Narcotic  Drug  Diseases  and  Allied  Ailments. 

The  hyperacidity,  which  is  troublesome,  is  due  to 
acetic,  butyric,  or  lactic  acid  fermentation.  Hydro- 
chloric acid  retards  the  development  of  or  destroys 
these  ferments  and,  therefore,  prevents  an  acid  stomach. 
This  acid  should  be  given  in  doses  of  about  5  minims 
of  chemically  pure  acid  in  %  glass  of  water  immediately 
before  or  immediately  following  the  meal.  A  smaller 
dose  than  that  does  not  meet  the  requirements  in  these 
cases. 

HYPNOTICS. 

Of  the  several  hypnotics  in  common  use  the  author 
has  found  veronal  the  most  dependable,  but  there  is  a 
decided  objection  to  its  use  in  drug  cases.  While  7%  to 
10  grains  of  veronal  is  probably  the  most  reliable  hyp- 
notic which  brings  prolonged  sleep,  the  fact  that  it  is  so 
abiding  in  its  effects  makes  it  objectionable.  On  the  day 
following  the  dose  there  is  a  degree  of  lassitude  and 
languor  which  is  really  distressing  to  the  patient.  Still 
in  some  cases  a  dose  of  veronal  for  one  or  two  nights 
after  the  drug  is  withdrawn  is  not  only  allowable,  but  it 
may  serve  a  very  good  purpose. 

Trional  and  sulphonal  in  doses  of  20  to  30  grains  are 
reliable  hypnotics  in  narcotic  addiction  cases.  Their 
effects  are  not  so  prolonged  as  that  of  veronal ;  neither 
are  they  followed  by  so  great  depression. 

It  is  the  author's  rule  to  discourage  the  use  of  hyp- 
notics in  all  cases,  but  there  are  instances  in  which  their 
use  is  expedient.  However,  he  insists  that  it  is  much 
better  for  the  patient  to  get  along  with  three  or  four 
hours'  sleep  obtained  without  the  aid  of  any  narcotic 
or  hypnotic  than  it  is  to  have  a  longer  sleep  under  the 
effects  of  any  one  of  these  remedies.  Therefore,  when 
a  patient  is  getting  as  much  as  four  hours5  sleep  out  of 
each  twenty-four  hours  no  hypnotic  is  given.  Under  the 


Ergot,  an  Unreliable  Remedy.  229 

plan  of  treatment  outlined  in  this  work,  it  is  rarely  neces- 
sary to  give  hypnotics  at  all,  as  it  is  the  exception  for  a 
patient  not  to  sleep  as  much  as  four  hours  out  of  twenty- 
four. 

ERGOT. 

Ergot  has  been  highly  extolled  by  some  for  its 
effects  in  the  treatment  of  narcotic  drug  addiction,  but 
the  author  has  been  totally  disappointed  in  this  remedy. 
If  the  claim  of  Livingston,  its  chief  advocate,  that  ergot 
has  an  elective  action  for  any  set  of  blood-vessels  which 
is  dilated,  could  be  verified  it  would  be  a  universal 
remedy  for  almost  all  diseases. 

In  every  inflammatory  condition  the  blood-vessels  of 
the  inflamed  parts  are  excessively  filled  with  blood.  If 
ergot  had  an  elective  action  that  would  contract  these 
overfilled  blood-vessels  and  restore  equilibrium  in  circu- 
lation it  would  be  almost  a  specific  cure  for  many  of  the 
diseases  we  are  called  upon  to  treat.  The  author  has 
tried  this  drug  faithfully  and  has  been  entirely  unable  to 
verify  these  claims  of  Livingston;  therefore,  he  has 
thrown  it  aside  as  of  no  value  in  the  treatment  of  drug 
addiction. 

If  it  has  any  effect  at  all  it  must  be  because  it  acts  as 
a  placebo  upon  the  mind  of  both  the  physician  and  the 
patient.  In  that  way,  if  the  physician  is  sufficiently 
credulous  and  the  patient  is  sufficiently  responsive  to 
suggestion,  it  might  allay  irritability  of  the  patient  and 
satisfy  the  mind  of  the  physician,  but  no  practical  thera- 
peutist can  afford  to  depend  upon  a  remedy  the  effect  of 
which  is  so  uncertain  and  disappointing  as  is  that  of 
ergot. 

QUININE  BY  INUNCTION. 

Among  the  complications  to  be  guarded  against  is 
malaria.  Drug  habitues  resist  acute  outbreaks  of 


230  Narcotic  Drug  Diseases  and  Allied  Ailments. 

malaria,  but  the  system  becomes  infected  with  germs  of 
the  type  which  causes  the  chronic  malarial  manifesta- 
tions, and  when  the  drug  is  withdrawn  they  often  give 
trouble,  the  symptoms  being  those  usually  dependent 
upon  chronic  malarial  toxemia.  In  other  cases  an  acute 
malarial  attack  similar  to  those  which  are  known  to  be 
precipitated  by  a  change  of  altitude  will  follow  the  with- 
drawal of  the  opiate.  This  should  be  watched  for  and 
upon  its  first  appearance  the  patient  should  be  saturated 
with  quinine. 

The  author's  eighteen  years'  general  practice  in  a 
malarial  climate  led  him  to  devise  a  method  of  intro- 
ducing quinine  into  the  patient's  system  which  has 
served  him  a  good  purpose  in  the  treatment  of  drug 
addiction. 

Patients  of  this  class  do  not  take  medicine  by  the 
mouth  as  well  as  the  average  person,  and  when  medi- 
cines are  given  to  them  by  the  mouth  an  unfavorable 
impression  is  often  made  upon  them ;  therefore,  it  is  very 
convenient  to  be  able  to  give  them  all  the  quinine  that 
may  be  needed  without  encumbering  their  stomachs 
with  it. 

This  can  readily  be  done  by  inunction  by  giving  the 
quinine  dissolved  in  glycerin. 

In  the  treatment  of  malarial  diseases  it  frequently 
becomes  a  matter  of  importance  to  introduce  quinine  into 
the  system  by  other  routes  than  by  the  stomach,  because 
the  stomach  may  be  so  irritable  that  it  will  not  retain  it, 
or  so  disordered  that  it  will  not  appropriate  medicinal 
agents  introduced  into  it.  In  these  conditions  quinine 
inunctions  have  long  been  resorted  to,  but  it  seems  that 
little  thought  has  been  given  to  the  mode  of  preparing 
quinine  for  this  purpose. 

The  method  almost  universally  employed  is  to  mix 
quinine  with  lard  or  vaselin  and  rub  the  patient  with  it. 


Quinine  by  Inunction.  231 

There  is  no  doubt  but  that  thousands  of  helpless  children 
have  been  slain  by  the  malarial  germ  while  their  physi- 
cian stood  by  and  credulously  depended  upon  securing 
the  effects  of  quinine  by  this  impossible  method.  The 
same  fatal  results  have  often  occurred  in  adult  patients 
because  of  the  failure  of  a  congested  stomach  to  absorb 
the  quinine  given  by  the  mouth. 

The  principles  involved  in  the  successful  administra- 
tion of  any  substance  by  inunction  are  that  the  remedy 
must  be  soluble  in  the  medium  employed,  and  the  com- 
pound, when  completed,  must  have  such  chemical  affinity 
for  the  blood  as  to  induce  osmotic  action  when  applied 
to  the  skin,  or  have  such  physical  properties  as  to  admit 
of  being  forced  through  the  skin  by  mechanical  pressure. 

None  of  the  salts  of  quinine  are  soluble  in  lard  or 
vaselin,  and  it  is  certain  that  these  substances  have  no 
chemical  affinity  for  an  alkaline  watery  solution  like  the 
blood.  Crystalline  substances  do  not  admit  of  being 
forced  through  the  skin  mechanically;  therefore,  it 
would  seem  quite  unreasonable  to  undertake  to  admin- 
ister quinine  by  inunction  in  such  a  medium.  Lanolin  is 
better,  because  it  is  more  miscible  with  the  blood,  and 
when  inunction  is  to  be  carried  out  simply  as  a  mechani- 
cal process,  as  in  the  use  of  mercury  by  inunction,  it  is 
an  ideal  medium,  but  it  is  not  a  satisfactory  medium  for 
quinine  inunction,  because  quinine  is  not  soluble  in  it, 
and  crystalline  substances  cannot  be  made  to  pass 
through  the  integument  unless  they  are  in  solution. 

There  is,  however,  a  medium  in  which  some  of  the 
salts  of  quinine  may  be  administered  by  inunction  with 
perfect  success.  It  is  glycerin. 

The  muriate  and  bisulphate  of  quinine  are  readily 
soluble  in  warm  glycerin  in  the  proportion  of  I  part  of 
quinine  to  3  parts  of  glycerin,  thus  making  a  25  per 


232  Narcotic  Drug  Diseases  and  Allied  Ailments. 

cent,  solution  of  quinine.  The  glycerin  of  this  compound 
has  such  an  affinity  for  the  water  of  the  blood  that  it 
passes  readily  through  the  integument  and  carries  with 
it  the  quinine  which  it  holds  in  perfect  solution.  Neither 
the  sulphate  nor  bromide  of  quinine  are  soluble  in 
glycerin;  therefore,  they  are  not  fit  to  be  used  in  this 
way. 

In  the  more  severe  forms  of  pernicious  malarial  dis- 
eases, if  quinine  is  administered  by  the  stomach,  rectum, 
or  even  hypodermically,  the  absorbents  may  be  so  de- 
ranged that  they  will  not  take  it  up,  but  so  long  as  the 
blood  is  circulating,  if  one  of  the  soluble  salts  of  quinine 
be  dissolved  in  glycerin  and  applied  to  the  skin,  it  will 
pass  into  the  blood,  the  skin  acting  merely  as  a  dialyzing 
membrane. 

This  is  essentially  a  chemical  process,  and  its  success 
does  not  depend  upon  the  activity  of  the  secretions  or, 
in  fact,  of  any  of  the  vital  functions  except  the  circula- 
tion of  the  blood.  A  patient  can  be  quininized  as 
promptly  and  as  thoroughly  by  inunction  with  this 
glycerole  of  quinine  as  by  any  other  mode  of  administra- 
tion, and  it  is  certainly  much  to  be  preferred  to  the 
hypodermic  method.  In  fact,  the  author  has  no  hesita- 
tion in  saying  that  the  patient  can  be  more  quickly  and 
more  certainly  quininized  by  this  form  of  inunction  than 
by  any  method  except  the  intravenous  method,  and  that 
is  hardly  to  be  thought  of  as  a  mode  of  administration 
of  quinine. 

This  mode  of  administration  of  quinine  is  suitable 
for  either  adults  or  children ;  but  in  estimating  the  dose, 
allowance  should  be  made  for  waste,  because  some  may 
be  wasted  by  contact  with  the  clothing  before  all  the 
compound  has  been  taken  up.  A  convenient  form  of 
ordering  this  compound  is : — 


Glycerole  of  Quinine.  233 

I£   Quinine  muriate 5ij. 

Glycerin  (warm)  Sviij. 

M.  et  ft.  sol.    Sig. :    Use  5ij  as  inunction  for  adult. 

If  quinine  is  given  hypodermically  the  injection  irri- 
tates the  site  of  injection,  causing  more  or  less  tume- 
faction. The  tumefaction  retards  the  absorption  of  the 
solution,  and  often,  especially  in  pernicious  types  of 
malaria  in  which  there  is  poor  capillary  circulation,  by 
cutting  down  on  the  site  of  the  injection,  crystals  of 
quinine  may  be  found  several  days  after  the  injection. 
It  is  evident  that  this  quinine  lying  in  the  cellular  tissues 
has  no  effect  on  the  malarial  germs  in  the  patient's  blood. 

When  quinine  is  indicated  at  all,  in  a  drug  habitue 
or  any  other  malarial  case,  a  quantity  sufficient  to  destroy 
the  life  of  the  malarial  germ  should  be  introduced  into 
the  blood  by  the  quickest  method  available.  This  can  be 
done  in  thirty  minutes'  time  by  the  author's  inunction 
method. 

Twenty  grains  of  quinine,  when  actually  introduced 
into  the  patient's  blood,  is  an  effective  dose.  To  be 
certain  to  get  that  quantity  into  the  circulation  with 
promptness,  30  grains  of  the  muriate  or  bisulphate 
should  be  dissolved  in  i1/?  or  2  teaspoonfuls  of  glyc- 
erin and  this  rubbed  into  the  patient's  skin,  applying  it 
to  the  abdomen,  and  to  the  inner  aspect  of  the  thighs 
and  arms.  A  moderate  degree  of  friction  should  be  used 
in  applying  this,  and  it  should  be  continued  until  all 
the  glycerin  has  disappeared  from  the  surface.  Ten  to 
fifteen  minutes  is  long  enough  to  keep  up  the  friction. 

The  hygroscopic  nature  of  the  glycerin,  its  affinity 
for  the  water  in  the  moving  stream  of  blood,  causes  it  to 
pass  readily  through  the  skin  into  the  blood.  The  stimu- 
lation of  the  capillary  circulation  by  the  friction  hastens 
this  process. 


234          Narcotic  Drug  Diseases  and  Allied  Ailments. 

Drug  patients  coming  from  a  malarial  district  during 
the  latter  part  of  the  summer  or  early  fall  months  should 
be  quininized  as  soon  as  they  are  taken  off  the  drug, 
thus  forestalling  the  development  of  malarial  complica- 
tions. A  full  dose  of  quinine  (20  to  30  grains)  given  at 
bedtime  by  inunction  has  a  very  happy  effect  on  those 
patients. 

Quinine  in  full  doses  is  antipyretic  and,  therefore, 
sedative,  and  a  patient  often  secures  a  full  night's  sleep 
from  the  effects  of  a  full  dose  given  at  bedtime,  but  if  it 
is  attempted  to  quininize  the  patient  by  the  administra- 
tion of  small  doses  by  the  mouth  the  nervousness,  tem- 
perature, and  discomfort  of  the  patient  will  be  markedly 
increased. 

The  antipyretic  effect  of  quinine  persists  for  twenty- 
four  hours  or  more  and  does  much  to  overcome  any 
aching  of  the  limbs  or  back  from  which  the  patient  will 
certainly  suffer  if  he  has  a  chronic  malarial  infection.  It 
can  be  used  at  times  in  drug  patients  with  distinct  benefit, 
even  where  there  is  no  malarial  complications  present, 
this  being  due  to  its  prolonged  antipyretic  effects. 


CHAPTER  XI. 

PHYSICAL  TRAINING. 

THE  fact  that  drug  users  who  have  been  taken  off 
a  drug  by  a  physiological  course  of  treatment  take  on 
flesh  at  a  rapid  rate  during  convalescence,  and  the  impor- 
tance of  having  that  newly  acquired  flesh  developed  into 
firm  muscular  fiber,  leads  the  author  to  include  a  chapter 
on  Physical  Training  in  this  work. 

The  author  does  not  claim  any  special  fitness  to  write 
on  such  a  subject,  but  with  the  hope  of  assisting  others 
and  of  giving  this  feature  of  the  management  of  con- 
valescent drug  patients  the  notice  it  deserves  he  here 
undertakes  to  present  some  measures  which  he  has  used 
to  great  advantage. 

The  ideal  condition,  that  under  which  the  most  satis- 
factory results  can  be  obtained,  is  to  have  a  well-equipped 
gymnasium  connected  with  the  institution  where  drug 
and  alcohol  patients  are  treated  and  to  require  patients 
who  are  in  a  suitable  stage  of  convalescence  to  spend 
several  hours  each  day  in  games  and  exercises  under  the 
supervision  of  a  competent  physical  director.  These 
facilities  are  not  available  in  many  instances;  therefore, 
the  author  suggests  measures  which  can  be  carried  out 
in  the  patient's  room. 

Dumb-bells,  heavy  weights,  or  horizontal  bars  cannot 
be  used  to  advantage  with  this  class  of  patients.  Such 
forms  of  exercise  are  too  violent  and  involve  the  use  of 
more  strength  than  such  patients  have.  A  course  of 
training  based  upon  muscular  resistance,  antagonizing 
one  set  of  muscles  by  another,  is  best  suited  for  use  in 
the  patient's  room.  Such  a  course  of  training  is  based 

(235) 


236  Narcotic  Drug  Diseases  and  Allied  Ailments. 

upon  physiological  laws,  to  which  the  author  wishes  to 
call  attention  in  this  connection. 

The  nutrition  of  the  body  takes  place,  mainly,  in  that 
invisible  space  between  the  termination  of  an  arterial 
capillary  and  the  beginning  of  a  venous  capillary.  As 
the  arterial  capillaries  diminish  in  size,  the  quantity  of 
blood  which  they  allow  to  pass  at  one  time  grows  per- 
sistently less  until  finally  the  capillary  is  of  such  small 
caliber  that  only  one  blood-corpuscle  can  pass  through  it 
at  a  time.  At  this  location,  a  string  of  red  and  white 
blood-corpuscles  passes  along  the  course  of  the  capillary, 
one  behind  another.  This  continues  until  the  veins  are 
entered,  and  as  the  veins  gradually  increase  in  size  the 
blood-corpuscles  double  up,  getting  two  by  two,  and 
three  by  three,  and  so  on  until  the  blood-current  is  again 
of  considerable  volume,  and  then  it  is  carried  to  the 
heart. 

In  that  space  between  the  termination  of  an  arterial 
capillary  and  the  beginning  of  a  venous  capillary,  the 
blood-corpuscles  come  in  direct  contact  with  the  cell 
tissues  of  the  body.  These  parts  are  universal;  that  is 
to  say,  all  parts  of  the  body  are  so  fully  supplied  with 
blood-vessels  that  there  is  no  particular  spot  at  which 
this  condition  of  affairs  does  not  exist. 

Any  course  of  exercise  which  will  increase  the 
activity  of  the  capillary  circulation  increases  the  nutri- 
tion of  the  part.  A  sluggish  circulation  in  any  organ  or 
part  results  in  a  poorly  nourished  organ,  or  if  the  entire 
circulation  is  sluggish  the  body  is  poorly  nourished.  An 
active,  vigorous  circulation,  especially  an  active  capillary 
circulation,  insures  increased  nutrition  throughout  the 
body. 

When  we  consider  the  forces  which  govern  the  cir- 
culation of  the  blood,  it  is  easy  to  understand  how  the 


Circulation,  Forces  Governing.  237 

heart,  acting  as  a  force  pump,  can  throw  the  blood  to  the 
most  remote  parts  of  the  body.  But  when  the  forces 
which  return  the  blood  to  the  heart  are  considered,  we 
find  that  they  are  nothing  like  so  positive.  In  fact,  it  is 
rather  difficult  to  explain  how  it  is  that  the  several  forces 
concerned  in  returning  the  blood  to  the  heart  are  of 
sufficient  potency  to  be  equal  to  that  task. 

Among  the  forces  which  aid  in  bringing  the  blood 
back  to  the  heart  is  the  pumping  effect  of  the  diaphragm. 
This,  operating  as  suction  pump,  lifts  the  blood  from  the 
lower  extremities,  bringing  it  into  the  vena  cava  and 
back  to  the  heart.  But  although  this  is  one  of  the  forces, 
it  is  not  the  principal  one  which  brings  the  blood  from 
the  exterior  of  the  body  into  the  center. 

The  principal  force  upon  which  the  return  of  the 
blood  to  the  heart  depends  is  the  rhythmic  contraction  of 
the  muscles  lying  alongside  of  the  veins,  and  in  which 
the  capillaries  are  imbedded.  It  is  the  tonic  state  of  the 
muscles  which  lie  alongside  of  the  veins  and  venous 
capillaries  which  supports  them,  and  by  their  contraction 
urges  the  blood  toward  the  heart. 

The  arterial  capillaries  have  a  muscular  coat,  which 
under  the  influence  of  the  nervous  system  is  capable  of 
contracting  or  relaxing,  regulating  the  caliber  of  those 
vessels,  but  the  veins  have  no  such  important  muscular 
element  in  their  walls.  They  are  more  like  elastic  tubes 
than  real  muscular  structures,  but  they  are  so  imbedded 
in,  and  surrounded  by,  muscular  tissues  that  all  parts  of 
the  veins  and  various  capillaries  are  well  supported  by 
the  contraction  of  these  outlying  muscular  tissues. 

If  the  muscles  are  flabby  and  relaxed  they  do  not 
give  the  veins  the  degree  of  support  they  require  to 
enable  them  to  maintain  the  weight  of  the  column  of 
blood  or  to  urge  it  on  back  to  the  heart. 


238  Narcotic  Drug  Diseases  and  Allied  Ailments. 

The  muscles  in  a  normal  condition  are  in  a  constant 
state  of  alternate  relaxation  and  contraction.  This  is 
not  perceptible  to  the  naked  eye  or  to  the  individual  him- 
self; nevertheless,  it  is  true.  This  alternate  relaxation 
and  contraction  of  the  muscles,  especially  the  contraction 
of  the  muscles,  forces  or  urges  the  blood  onward  to  a 
larger  part  of  the  vein.  As  the  blood  in  a  vein,  under 
such  pressure,  travels  in  the  direction  of  the  least  resist- 
ance, it  is  necessarily  urged  toward  the  heart,  that  being 
at  the  larger  end  of  the  veins. 

In  the  course  of  physical  training  herein  outlined, 
this  element  of  muscular  tension,  or  muscular  contrac- 
tion, is  voluntarily  increased.  Instead  of  depending 
upon  the  rhythmic,  intermitting  contraction  of  the 
muscles,  the  set  of  muscles  to  be  developed  are  put  under 
tension  by  direction  of  will,  and  this  tension  is  kept  up 
for  about  ten  seconds  before  a  period  of  relaxation  is 
allowed.  The  tense  contraction  of  the  muscle  squeezes 
the  venous  blood  out  of  the  contracted  muscle  and  urges 
it  on  toward  the  heart. 

This  state  of  tension  is  allowed  to  pass  away  and  a 
state  of  relaxation  is  established  in  its  stead,  when  the 
heart,  with  its  pumping  force,  rushes  a  new  supply  of 
arterial  blood  to  these  structures.  The  part  is  again  put 
under  tense  muscular  contraction  and  this  blood  is  in 
turn  squeezed  out  of  the  muscle  and  passed  on  toward 
the  heart,  making  room  for  a  new  influx  of  blood. 

This  insures  a  more  rapid  interchange  of  blood  in 
the  part  which  is  being  exercised,  and  this  more  rapid 
passage  of  blood  through  the  part,  accompanied  by  the 
nutritive  changes  which  such  improved  circulation  in- 
volves, develops  the  part  which  is  being  exercised. 

In  the  use  of  dumb-bells  or  other  weights,  gravity  is 
the  force  which  carries  the  weight  downward,  and  the 


Muscular  "Resistance  Work.  239 

contraction  of  the  muscles  which  are  made  to  lift  the 
weight  is  the  force  by  which  gravity  is  to  be  over- 
come. This  leads  to  the  development  of  the  flexor 
muscle,  but  no  effort  is  required  on  the  part  of  the  ex- 
tensor muscles  to  allow  the  weight  to  descend  toward  the 
earth ;  therefore,  those  sets  of  muscles  do  not  receive  the 
same  degree  of  development. 

The  dumb-bell  system  of  exercise  develops  the  body 
in  a  disproportionate  manner,  developing  the  flexor 
muscles,  but  leaving  the  extensors  undeveloped. 

Heavy  weights  overtax  the  heart  and  blood-vessels 
by  the  constant  contraction  which  handling  them  in- 
volves, but,  by  making  the  contraction  intermittent,  by 
means  of  alternate  relaxation  and  contraction,  the  cir- 
culation of  the  blood  is  not  obstructed.  On  the  contrary, 
with  each  relaxation  the  blood  flows  from  the  artery  into 
the  capillaries  and  with  each  contraction  it  is  forced  from 
the  capillaries  into  the  veins  and  helped  in  its  course 
toward  the  heart. 

Before  beginning  to  take  any  kind  of  a  course  of 
physical  training,  the  patient  should  be  examined  to 
ascertain  the  condition  of  the  heart.  If  a  structural 
lesion  is  present,  the  course  of  exercise  should  be  so 
modified  as  not  to  put  undue  strain  upon  the  heart  or  to 
otherwise  overtax  the  strength  of  the  patient. 

Careful  measurements  of  the  body  should  be  made 
in  order  to  ascertain  what  parts  are  most  deficient  in 
development  and  the  course  of  exercise  should  be  so 
regulated  as  to  devote  more  time  to  the  development  of 
these  defective  parts.  The  weight,  height,  and  measure- 
ments of  the  body  of  the  patient  should  be  recorded  at 
the  beginning  of  the  course  of  training  and  the  patient 
should  be  reweighed  and  measured  about  every  ten  days. 
The  comparison  of  these  records,  one  with  the  other, 


240 


Narcotic  Drug  Diseases  and  Allied  Ailments. 


indicates  the  progress  that  is  being  made,  and,  as  the 
improvement  of  the  patient  can  usually  be  verified  by  the 
scales  and  the  tape  line,  these  give  substantial  grounds 
for  encouragement. 

The  following  measurements  should  be  taken  and 
recorded : — 


SHOULDER 


Date  . . 

Name  . 
Weight 
Height 
Age  . . . 


CHEST 


WAIST 


1.  Girth  of  neck. 

2.  Girth  of  shoulders. 

3.  Girth  of  chest,  natural. 

4.  Girth  of  chest,  contracted. 

5.  Girth  of  chest,  expanded. 

6.  Girth  of  right  upper  arm. 

7.  Girth  of  left  upper  arm. 

8.  Girth  of  right  forearm. 

9.  Girth  of  left  forearm. 

10.  Girth  of  waist. 

11.  Girth  of  hips. 

12.  Girth  of  right  thigh. 

13.  Girth  of  right  calf. 

14.  Girth  of  left  thigh. 

15.  Girth  of  left  calf. 


The  position  of  these  measurements  is  indicated  in 
illustration. 

That  there  may  be  a  standard  with  which  the 
measurements  of  the  patient  under  consideration  can  be 
compared,  the  following  tables  are  given : — 


iCALF 


ANKLE 


Ideal  Proportions,  Men  and  Women, 


241 


TABLE  REPRESENTING  THE  POPULARLY  ACCEPTED  PROPORTION 
FOR  ADULT  MEN.* 


Height. 

I 

a 

1 

^ 

I 

i 

15 

1 

• 

0 

0 

"3 

"3 

* 

* 

o 

S 

£ 

* 

S 

O 

5  ft. 

103-107 

U| 

33 

81 

29 

17 

5  ft.     1  in. 

107-111 

34 

9£ 

29* 

in 

5  ft.     2  in. 

111-116 

12" 

35 

91 

30 

17} 

5  ft.     3  in. 

116-121 

12} 

36 

^5 

10 

30} 

18 

jA 

5  ft.     4  in. 

121-127 

13 

37 

i 

10f 

31 

18} 

i 

5  ft.    5  in. 

127-133 

13} 

38 

a 

10  1 

31} 

19 

o 

5  ft.     6  in. 

133-140 

14 

39 

C/3 

3 

lit 

32 

19} 

CO 

i 

5  ft.     7  in. 

140-147 

14} 

40 

11} 

32} 

19| 

a 

5  ft.     8  in. 

147-155 

15 

41 

i 

lit 

33 

20 

3 

5  ft.     9  in. 

155-164 

15} 

42 

05 
CQ 

12J 

33} 

22 

i 
w 

5  ft.  10  in. 

164-174 

16 

43 

12f 

34 

23 

5  ft.  11  in. 

174-185 

16} 

44 

13 

34} 

24 

6  ft. 

185-200 

17 

45 

13| 

35 

24 

*Taken  from  "Physical  Training,"  by  Albert  Treloar. 

Women,  as  a  rule,  come  closer  to  the  ideal  figure  than 
men  in  all  particulars,  except  the  waist.  The  unsightly 
notch  in  the  side  contour  of  many  women  at  the  waist  is, 
no  doubt,  due  to  the  corset  and  lack  of  exercise.  Follow- 
ing are  the  measurements  of  six  New  York  artists' 
models,  supposed  to  have  figures  practically  correspond- 
ing with  the  classical  ideals : — 

TABLE  REPRESENTING  IDEAL  PROPORTION  FOR  WOMEN.* 


a 

g* 

1 

Height. 

a 

ts 

• 

j 

& 

to 

S 

. 

_"§ 

IB 

10 

to 

M 

i 

0 

*c 

o 

S 

2 

B 

"3 

o 

a 

% 

* 

• 

* 

E 

"" 

o 

H 

H 

* 

u 

* 

5  ft.  3     in. 

20 

106 

Sf 

Bt 

9} 

12| 

20| 

33} 

24 

31 

13 

5  ft.  4    in. 

19 

107 

6 

8} 

9} 

12* 

20 

32 

22} 

30 

12 

5  ft.  4}  in. 

24 

130 

6 

10 

10} 

13 

22 

36i 

25 

32 

121 

5  ft.  5    in. 

25 

138 

6 

10 

11 

14 

23 

38 

26 

33 

13 

5  ft.  6    in. 

23 

140 

6 

10 

10} 

14} 

25 

40 

25 

34 

13 

5  ft.  8    in. 

27 

165 

6} 

11 

12} 

15} 

27 

42 

31 

35 

14} 

*  Albert  Treloar. 


16 


242  Narcotic  Drug  Diseases  and  Allied  Ailments. 

After  having  made  the  physical  examination  and  the 
measurements  above  indicated,  the  patient  may  be 
started  on  the  course  of  exercise,  being  guided  as  to  the 
amount  and  character  of  exercise  by  the  information 
gained  from  the  measurements  and  examination. 

When  no  special  defects  are  revealed  by  the  measure- 
ments and  examination,  but  where  these  only  show 
general  deficiency,  extending  practically  to  all  the  mus- 
cular structures,  the  author  thinks  it  best  to  begin  with 
the  movements  indicated  by  the  following  cuts,  Nos.  I  to 
8,  inclusive,  and  to  practise  these  for  a  week  or  ten  days 
before  undertaking  a  larger  number  of  exercises. 

TIME  FOR  TAKING  EXERCISES. 

The  hours  at  which  the  exercises  should  be  taken 
will  depend  upon  the  hours  at  which  the  meals  are  taken. 
The  exercises  should  not  be  taken  during  the  time  in 
which  stomach  digestion  is  in  active  progress.  Since  it 
requires  about  three  hours  for  the  digestion  of  a  meal, 
the  exercise  period  should  be  as  much  as  three  hours 
after  each  meal. 

Usually  our  meals  are  taken  at  about  7  A.M.,  at  noon, 
and  at  6  P.M.  If  the  patient  is  quite  weak  and  therefore 
not  able  to  take  much  exercise  at  any  one  time,  it  is  best 
to  have  four  exercise  periods  per  day.  One  about  ah 
hour  before  each  meal  and  one  at  bedtime,  say,  6  and  1 1 
A.M.  and  5  and  9  P.M.  These  periods  should  vary  in 
length  from  fifteen  to  forty-five  minutes,  according  to 
the  strength  of  the  patient.  They  should  not  be  so  long 
as  to  bring  the  patient  to  a  state  of  severe  fatigue,  but 
the  exercise  should  be  regulated  so  as  to  be  as  vigorous 
and  should  be  continued  for  as  long  a  time  as  the  patient 
can  stand  without  severe  fatigue. 


Time  for  Taking  Exercises.  243 

The  best  results  can  be  obtained  only  when  a  cold 
sponge  bath  is  taken  following  each  period  of  exercise; 
this  certainly  should  never  be  omitted  following  the  early 
morning  and  night  exercise  period.  A  shower  bath  fol- 
lowed by  brisk  rubbing  is  better. 

EXERCISE  No.  1. 

Stand  erect  as  indicated  by  Cut  i.  Extend  the  arms 
to  the  side,  full  length,  level  with  shoulders;  close  the 


Exercise  No.  i. 

fists,  and  make  all  muscles  of  the  arms,  forearms,  and 
shoulders  rigid,  and,  with  the  muscles  of  the  back  of 
the  arms  and  shoulders,  make  a  determined  effort  to 
hold  the  arms  in  the  position  assumed,  but  with  the 
flexor  muscle  reinforced  by  the  will.  In  spite  of  this 
resistance,  bring  the  arms  together  as  indicated  in  the 
cut.  Let  this  movement  be  made  very  slowly  and  with 
the  greatest  possible  effort.  After  the  hands  have  been 


244 


Narcotic  Drug  Diseases  and  Allied  Ailments. 


brought  together,  arms  straight  in  front,  relax  the  ten- 
sion and  restore  the  arms  to  the  position  from  which 
the  movement  was  started.  Allow  this  period  of  relaxa- 
tion to  continue  for  as  great  a  length  of  time  as  was 
consumed  in  bringing  the  arms  together  under  tension; 
then  repeat  the  movement,  and  continue  to  repeat  it  with 
alternate  tension  and  rest  until  it  has  been  made  12  times. 
Do  not  forget  that  in  making  this  or  any  other  move- 
ment the  more  rigid  the  muscles  are  made,  and  the 
greater  the  degree  of  resistance  to  the  movement  to  be 
made,  the  more  benefit  will  result.  The  tense  contrac- 
tion of  the  muscle  overcomes  venous  stasis,  forces  the 
venous  blood  out  of  the  part,  and  then  the  period  of 
relaxation  allows  the  heart  to  fill  the  part  with  a  fresh 
supply  of  arterial  blood  ready  to  give  off  its  nutrient 
elements. 

EXERCISE  No.  2. 

Assume  position  shown  in 
Cut  2,  hands  resting  on  hips. 
Make  muscles  of  arms  and 
shoulders  rigid  and  then  force 
elbows  to  the  rear  as  far  as 
possible.  Maintain  that  posi- 
tion about  ten  seconds;  then 
relax;  return  to  first  position, 
and  after  a  moment's  pause 
repeat.  As  the  arms  are 
forced  backward,  take  a  deep 
breath,  filling  the  lungs  as  fully 
as  possible,  and  expel  this  air 
as  the  arms  are  brought  back 

to  the  position  of  starting.     Repeat  20  times  at  each 

exercise  period. 


Exercise  No.  2. 


Muscular  Resistance  Work. 


245 


EXERCISE  No.  3. 

This  exercise  consists  of  the  imaginary  lifting  and 
lowering  of  a  heavy  weight.  Flex  the  right  arm  as 
shown  in  cut  and  make  muscles  rigid,  and  with  the 
muscles  on  the  back  of  the  arm  en- 
deavor to  hold  it  in  that  position,  but  in 
spite  of  that  resistance  force  the  arm 
to  a  perpendicular  position  above  the 
head,  keeping  the  muscles  as  rigid  as 
possible.  When  this  position  has  been 
reached,  instead  of  holding  to  the  idea 
that  you  are  lifting  and  holding  up  a 
heavy  weight,  reverse  the  thought  to 
the  idea  that  you  have  taken  hold  of 
something  that  must  be  pulled  down, 
but  the  fact  that  it  is  very  difficult  to 
move  requires  the  use  of  all  the  force 
at  your  command  to  pull  it  down.  Per- 
sist in  that  effort  with  that  idea  until 
the  arm  has  been  brought  down  to 
position  it  occupied  at  the  beginning  of 
this  movement.  The  entire  time  con- 
sumed in  forcing  the  arm  up  and  bringing  it  down 
should  be  ten  to  twelve  seconds.  The  tension  should 
then  be  relaxed ;  the  arm  dropped  to  the  side  and  allowed 
to  rest  while  the  same  movements,  with  the  same  ideas 
in  mind,  are  made  by  the  left  arm.  These  movements 
should  be  repeated  twelve  times  with  each  arm  at  each 
exercise  period. 


Exercise  No.  3. 


246 


Narcotic  Drug  Diseases  and  Allied  Ailments. 


Exercise  No.  4. 


EXERCISE  No.  4. 

This  exercise  consists  in 
bending  the  body  from  side  to 
side,  and  is  not  strictly  a  re- 
sistance movement,  but  it  is 
.valuable  in  developing  the 
muscles  of  the  back,  sides,  and 
abdomen.  It  is  also  a  form  of 
abdominal  massage  and  pro- 
motes peristalsis.  Assume 
erect  position;  place  hands  on 
hips,  and  then  bend  the  body 
to  one  side  as  far  as  can  be 
done  without  losing  balance. 
Hold  in  that  position  a  few 
seconds ;  then  bend  to  the  other  side.  Repeat  this  move- 
ment 20  times. 

EXERCISE  No.  5. 

This  exercise  loosens  up  and  develops 
the  muscles  of  the  shoulders,  back,  sides, 
and  front  of  chest.  It  is  also  a  deep- 
breathing  exercise  and  if  properly  used 
increases  the  ability  to  expand  the  chest. 
Stand  erect  with  arms  resting  by  sides 
and  raise  shoulders  as  high  as  possible, 
and  as  this  is  being  done  inflate  the  lungs 
to  their  utmost  capacity.  Make  the 
muscles  on  the  back  of  the  shoulders  rigid, 
and  put  all  effort  possible  into  the  move- 
ment. When  the  shoulders  have  been 
forced  to  as  high  a  point  as  possible,  main- 
tain that  position  a  few  seconds ;  then  relax  the  muscles 
and  depress  the  shoulders  to  as  low  a  point  as  possible, 


Exercise  No.  5. 


Muscular  Resistance  Work. 


247 


at  the   same   time  expelling  the   air   from  the   lungs. 
Repeat  this  movement  20  times. 

EXERCISE  No.  6. 

Assume  upright  position 
as  shown  in  cut ;  make  muscles 
of  the  neck  rigid;  turn  face  to 
one  side  as  far  as  possible,  and 
endeavor  to  hold  that  position, 
but  in  spite  of  that  effort 
slowly  twist  the  neck  so  as  to 
turn  the  face  to  the  opposite 
side,  holding  the  muscles  rigid 
during  the  entire  turning 
movement.  After  the  face  has 
been  turned  to  the  opposite 
side  as  far  as  possible  and  this 
state  of  rigidity  has  been  main- 
tained for  about  ten  seconds,  relax  and  allow  a  period  of 
relaxation  to  continue  for  about  the  same  length  of  time ; 
then  repeat  the  movement.  Repeat  20  times. 

EXERCISE  No.  7. 

Lie  on  back  on  floor  or  other  firm  place ;  clasp  hands 
across  stomach ;  then  bend  head  and  shoulders  up  as  far 


Exercise  No.  6. 


Exercise  No.  7. 

as  possible,  bending  in  the  neck,  shoulders,  and  upper 
part  of  the  body  only,  but  not  at  hips.    Inflate  the  lungs 


248          Narcotic  Drug  Diseases  and  Allied  Ailments. 

as  fully  as  possible  before  beginning  to  bend  upward, 
and  as  the  shoulders  are  brought  forward  and  upward 
expel  the  air  from  the  lungs ;  at  the  same  time  compress 
the  lower  part  of  the  chest  with  the  elbows  and  arms, 
thus  expelling  as  much  of  the  residual  air  from  the  lungs 
as  possible.  When  the  body  has  been  bent  to  as  high  a 
point  as  possible  and  held  in  that  position  a  few  seconds, 
lower  the  head  and  shoulders,  slowly,  to  the  horizontal 
position.  As  this  is  reached,  take  a  deep  breath,  inflating 
the  lungs  to  their  utmost  capacity.  Expel  this  air  and 
inflate  again.  Do  this  three  times,  and  then  repeat  the 
movement,  bending  up  as  in  first  instance.  This  move- 
ment taxes  the  strength  considerably,  and  it  is  best  not 
to  use  it  more  than  8  to  10  times  at  the  beginning,  but 
the  number  of  movements  should  be  increased  from  day 
to  day  until  20  to  30  are  reached.  This  is  a  good  breath- 
ing exercise  and  strengthens  all  the  muscles  of  the  upper 
part  of  the  body,  especially  the  abdominal  muscles. 

EXERCISE  No.  8. 

Lie,  face  down,  on  a  rug  on  floor  or  other  firm  place ; 
place  hands  in  position  shown  in  cut.  Make  entire  body 
rigid  and  raise  upward  to  position  indicated  by  dotted 
lines ;  hold  this  position  for  about  ten  seconds,  the  weight 
of  the  body  resting  on  the  hands  and  toes,  all  muscles 
being  rigid;  then  lower  body  to  first  position,  relaxing 
only  when  that  position  is  reached.  Rest  a  few  moments 
and  repeat  the  movement.  This  movement  should  be 
made  about  10  times  at  the  beginning  and  increased 
from  day  to  day  until  20  to  30  are  reached. 

By  the  time  the  foregoing  eight  exercises  have  been 
carried  out  faithfully  at  each  exercise  period  for  a  week 
or  two  weeks,  the  strength  will  have  usually  increased 


Muscular  Resistance  Work. 


249 


sufficiently  to  allow  the  addition  of  a  few  more  move- 
ments. All  or  a  part  of  the  seven  movements,  next 
described,  should  then  be  added,  and  these  should  be 
practised  in  connection  with  the  eight  first  used.  It  is 
best  to  practise  the  newly  added  movements  first,  and 
then  go  over  those  to  which  the  patient  has  become  ac- 
customed. 

If  it  is  found  that  the  carrying  out  of  all  the  exercises 
at  one  time  fatigues  the  patient  unduly,  a  period  of  rest 


Exercise  No.  8. 

of  a  quarter  of  an  hour  or  half  an  hour  should  be  allowed 
and  then  the  exercises  resumed.  In  this  particular,  exer- 
cises for  convalescents  differ  from  exercises  for  those 
who  are  already  in  a  fair  state  of  health,  and  who  can 
only  spare  short  intervals  from  their  daily  vocation  to 
devote  to  physical  development.  The  convalescent  has 
nothing  else  to  do  and  can  devote  all  the  time  that  can  be 
used  to  advantage  to  the  development  of  strength.  If  he 
is  only  able  to  carry  out  a  few  movements  at  first,  and  to 
do  that  very  imperfectly,  let  that  much  be  done  and 
persisted  in  until  the  strength  thus  acquired  will  enable 
him  to  do  more;  then  add  such  other  movements  as  his 
strength  will  permit. 


250 


Narcotic  Drug  Diseases  and  Allied  Ailments. 


Exercise  No.  9. 


EXERCISE  No.  9. 

Assume  upright  position  as  shown 
in  cut,  and  place  hands  on  hip;  then 
circle  head  round  and  round,  bending 
neck  as  far  as  possible  in  every  direc- 
tion, making  as  large  circle  with  the 
movement  of  the  head  as  possible. 
Circle  in  one  direction  5  times  around 
and  reverse.  Continue  this  alternate 
circulating  of  the  head,  first  in  one 
direction  and  then  the  other,  until  30 
circles  have  been  made,  15  times  in  each 
direction. 


EXERCISE  No.  10. 

Assume  standing  position  with 
the  hands  resting  on  hip;  then 
bend  neck  forward  as  far  as  pos- 
sible and  then  backward  as  indi- 
cated in  cut.  Make  muscles  of  the 
neck  rigid,  and  hold  them  so  while 
bending  in  one  direction  and  relax 
as  the  motion  is  made  in  the  re- 
versed direction.  Do  this  15  times 
at  each  exercise  period. 


Exercise  No.  10. 


Muscular  Resistance  Work. 


251 


EXERCISE  No.  11. 

Assume  upright  position, 
with  the  hands  resting  on  hip 
as  indicated  in  cut ;  then  circle 
body,  bending  at  waist  as  far 
as  possible.  Make  as  large 
circle  by  movement  of  the 
shoulders  and  head  as  possible, 
but  do  not  bend  below  hips. 
This  circle  should  be  made  in 
one  direction  5  or  6  times; 
then  the  motion  should  be  re- 
versed. Circles  alternating  to 
the  right  and  to  the  left  should 
be  continued  until  30  move- 
ments of  this  kind  have  been  made. 


Exercise  No.  u. 


Exercise  No.  12. 


EXERCISE  No.  12. 

Assume  upright  posi- 
tion as  indicated  by  cut 
and  raise  the  hands  per- 
pendicularly above  the 
head,  arms  together. 
Then  while  holding  hands 
and  arms  in  same  rela- 
tion to  the  body  and  head, 
bend  forward  as  indi- 
cated by  dotted  lines. 
This  is  a  motion  made  by 
bending  at  the  hips,  but 
not  of  any  other  part  of 
the  body.  Bend  forward 
as  far  as  possible,  but  do 
not  allow  position  of  the 


252          Narcotic  Drug  Diseases  and  Allied  Ailments. 

arms  to  change  in  their  relation  to  the  head.  After 
bending  forward  as  far  as  possible,  then,  without  drop- 
ping arms  or  changing  their  position  at  all,  raise  up  to 
the  position  from  which  you  started.  Make  the  muscles 
of  the  abdomen  very  rigid  on  the  upward  movement  and 
hold  them  so  until  the  first  position  has  been  reached; 
then  relax.  Rest  about  ten  seconds  between  the  move- 
ments and  then  repeat  as  in  the  first  instance.  This 
movement  strengthens  both  the  muscles  of  the  back  and 
abdomen,  and  should  be  made  about  10  times  at  each 
exercise  period. 


EXERCISE  No.  13. 

Assume  upright  position  with 
the  hands  resting  on  back  of  chair 
or  some  other  object  to  steady  the 
body;  then  raise  on  toes  as  high  as 
possible,  as  shown  in  cut.  Make 
all  the  muscles  of  the  lower  ex- 
tremities rigid.  Remain  in  this 
position  about  ten  seconds;  then 
relax  and  come  down  until  the 
feet  rest  flatly  on  the  floor.  Allow 
about  ten  seconds'  rest  and  then 
raise  on  the  toes  again.  Keep 
muscles  rigid  as  long  as  you  are 
standing  on  the  toes,  but  relax  en- 
tirely when  the  body  is  lowered  so  tfiat  the  soles  of  the 
feet  rest  on  the  floor.  This  movement  should  be  made 
from  10  to  20  times  at  each  exercise  period. 


Exercise  No.  13. 


Muscular  Resistance  Work. 


253 


EXERCISE  No.  14. 

This  is  directly  the  reverse  of 
exercise  No.  13,  that  is,  the  weight 
is  balanced  on  the  heel  with  the 
toes  raised  from  the  floor.  Stand 
on  the  heels  ten  seconds,  making  all 
of  the  muscles  of  the  legs  rigid 
during  that  time ;  then  relax,  bring- 
ing the  toes  down  for  about  the 
same  length  of  time.  Repeat  this 
movement  about  20  times  at  each 
exercise  period. 


Exercise  No.  14. 


EXERCISE  No.  15. 

Balance  weight  on  toes  as 
indicated  in  cut,  and  then 
lower  the  body  to  squatting 
position,  all  the  time  maintain- 
ing balance  on  toes.  Remain 
in  this  position  a  few  seconds 
and  then  raise  to  upright  posi- 
tion. Repeat  this  15  times  at 
each  exercise  period. 


Exercise  No.  15. 


254 


Narcotic  Drug  Diseases  and  Allied  Ailments. 


EXERCISE  No.  16. 

Stand  in  erect  position  and  lock 
hands  on  back,  resting  on  the  small 
of  the  back;  then  make  all  the 
muscles  of  the  arms  rigid,  and, 
while  holding  in  that  rigid  state, 
lower  the  hands  as  far  as  possible, 
as  indicated  by  dotted  lines  in  cut. 
Do  this  15  times  at  each  exercise. 
Keep  the  muscles  rigid  on  the 
downward  movement  only,  allow- 
ing a  period  of  relaxation  of  about 
ten  seconds  between  each  of  these 
movements. 


EXERCISE  No.  17. 

Assume  upright  posi- 
tion with  hands  on  hip; 
then  bend  the  body  for- 
ward as  far  as  can  be 
done  without  moving  the 
legs ;  then  bend  backward 
as  far  as  possible  with- 
out losing  balance.  This 
movement  should  be  made 
about  15  times  at  each 
exercise  period. 


Exercise  No.  17. 


Muscular  Resistance  Work. 


255 


Exercise  No.  18. 


EXERCISE  No.  18. 

Assume  upright 
position  with  the 
hands  and  arms  held 
downward,  forward, 
and  to  the  right; 
then  bend  body  to  the 
left  side  and  from 
that  position  bend  as 
far  to  the  other  side 
as  possible,  swinging 
the  hands  and  arms 
in  the  opposite  direc- 
tion at  each  move- 
ment of  the  body.  This  is  a  motion  of  the  body  and  arms 
only.  The  legs  should  be  kept  still.  Bend  just  above  hips 
and  in  the  shoulders;  swing  the  body  from  side  to  side. 
This  movement  should  be  made  about  15  times  at  each 
exercise  period. 

EXERCISE  No.  19. 

Assume  up- 
right position ; 
then  step  off  with 
right  foot  a  full 
^  step;  spring  for- 
ward and  down- 
ward, throwing 
the  weight  on  the 
right  foot,  hold- 
ing all  the  mus- 
cles of  the  lower 
extremities  rigid. 
Exercise  No.  19.  Stand  in  this  posi- 


256 


Narcotic  Drug  Diseases  and  Allied  Ailments. 


tion  about  ten  seconds;  then  assume  upright  position 
again,  relaxing  all  muscles  as  much  as  possible  as  that 
position  is  assumed.  The  arms  should  be  held  in  front 
as  the  movement  is  begun,  and  swung  out  to  each  side 
at  level  with  the  shoulders  as  the  forward  position  is 
taken.  This  is  indicated  by  dotted  lines  in  the  cut. 
Repeat  this  about  10  times  at  each  exercise  period. 


EXERCISE  No.  20. 

Assume  upright  posi- 
tion; bend  body  forward, 
hands  down  and  arms  to- 
gether. Then  forcibly  raise 
arms  upward  and  backward 
as  far  as  possible.  Repeat 
this  movement  10  to  15 
times  at  each  exercise 
period. 


Exercise  No.  20. 


EXERCISE  No.  21. 


Lie  on  the  floor  on  a  rug,  with  the  knees  drawn  up, 
the  legs  and  thighs  forming  a  right  angle.    Then  raise 


Exercise  No.  21. 


the  body  so  that  the  weight  will  rest  on  the  foot  and 
head,  bringing  the  body  up  as  high  as  can  be  done  in 
that  position.  This  position  is  indicated  by  dotted  lines 


Muscular  Resistance  Work.  257 

in  cut.  Repeat  this  10  times.  When  the  body  is  brought 
upward  and  is  resting  on  the  feet  and  head  only,  all  the 
muscles  of  the  body  should  be  made  as  rigid  as  possible 
and  held  so  for  about  ten  seconds;  then  a  period  of 
relaxation  should  be  allowed,  in  which  the  body  is 
brought  down  so  as  to  rest  on  the  floor  as  at  beginning. 

EXERCISE  No.  22. 

Lie  on  the  floor  on  a  rug;  place  hands  under  head; 
then  raise  to  sitting  position.    If  it  is  difficult  to  do  this 


Exercise  No.  22. 

without  something  to  keep  toes  and  feet  from  raising, 
let  the  toes  be  placed  under  some  article  of  furniture  so 
that  they  may  be  held  down.  This  exercise  should  be 
repeated  about  10  times  at  each  exercise  period.  After 
the  body  has  been  raised  to  erect  position,  it  should  be 
lowered  to  horizontal  position,  but  the  body  should  be 
lowered  gradually  and  not  allowed  to  fall  back  suddenly. 
Continue  to  hold  muscles  of  the  body  tense  during  the 
time  the  body  is  being  lowered,  and  then  relax ;  allow  a 
short  period  of  rest ;  then  repeat  movement. 

The  author  has  found  it  very  difficult  to  keep  patients 
interested  in  their  physical  development  to  such  a  degree 
as  to  secure  satisfactory  results.  In  some  cases  it  has 


17 


258 


Narcotic  Drug  Diseases  and  Allied  Ailments. 


been  found  that  some  simple  device  will  stimulate  their 
interest  and  lead  them  to  continue  their  work. 

In  such  cases  "the  simplex  exerciser,"  shown  in  the 
following  cuts,  has  been  found  satisfactory.  I_t  is  an 
inexpensive  and  convenient  device;  may  be  fastened  by 
screw  hook  to  window  casing  and  mop  board.  By  its 
use  in  the  seclusion  of  patient's  own  room  he  can  get  all 
the  exercise  he  wishes. 

The  following  cuts  show  its  use.  Many  movements 
not  here  shown  can  be  added.  By  its  persistent  use,  any 
part  of  the  body  can  be  developed.  It  may  be  used  to 
advantage  in  connection  with  any  or  all  the  exercises 
above  shown. 


DEEPENING  THE  CHEST 
Arm*  from  Front  Above  H«J 


CHEST  DEVELOPMENT 
H«nd»  from  front  to  level  with  ibould«r» 


Simplex  Exerciser. 


259 


Large  muscle  front  of  thigh. 
Rj»e  from  crouching  to  erect  position. 


STOMACH  EXERCISE 
Keep  Knee*  Stiff 


Broadening  the  Chest 
Hand*  up  Sideways 


BOWLING 
Step  out  with  Left  leg 


260  Narcotic  Drug  Diseases  and  Allied  Ailments. 


ROWING  EXERCISE 


E±r£) 


Hands  from  front  of  body  to  back 


SPINE  AND  STOMACH 
Body  from  Bent  to  Erect  Po»  ib 


CHAPTER  XII. 

DIET  DURING  CONVALESCENCE 
AND  AFTERWARD. 

DIET,  the  quantity  and  quality  of  food  which  will 
nourish  the  body  to  the  best  advantage,  is  a  matter  of 
importance  to  every  person,  but  to  those  who  are  con- 
valescing from  some  protracted  ailment  such  as  drug 
disease  it  is  of  greater  moment  than  to  persons  who  are 
already  in  a  fair  state  of  health. 

Almost  all  convalescent  patients  have  a  tendency  to 
eat  too  much.  While  this  is  true  of  most  persons  in 
apparent  health,  convalescents  do  not  bear  these  excesses 
as  well  as  do  stronger  persons.  Those  convalescing 
from  narcotic  drug  disease  seem  to  be  more  unfavorably 
affected  by  excesses  in  diet  than  any  other  convalescents, 
and  this  idiosyncrasy  continues  in  them  for  months,  if 
not  for  years,  after  they  have  in  every  other  respect  re- 
covered from  drug  influences. 

In  such  persons  excesses  in  diet  bring  on  suffering 
that  simulates  in  many  respects,  and  strongly  reminds 
them  of,  the  distress  they  experienced  when  they  were 
making  an  effort  to  reduce  the  quantity  of  drug  they 
were  using,  or  when  they  were  making  an  effort  to  leave 
it  off  altogether.  The  suffering  in  both  instances  arises 
from  the  same  cause — toxemia. 

The  system  of  a  person  habituated  to  a  narcotic  drug 
is  in  a  state  of  chronic  toxemia.  This  makes  the  anes- 
thetic and  narcotic  effect  of  the  drug  to  which  they  are 
addicted  necessary  to  their  comfort,  because  without  it 
the  nervous  system  rebels  so  strongly  against  the  pres- 
ence of  the  toxins  that  they  are  in  constant  distress. 

(261) 


262  Narcotic  Drug  Diseases  and  Allied  Ailments. 

When  the  quantity  of  drug  they  are  accustomed  to  take 
is  reduced  or  discontinued,  the  nervous  system  at  once 
becomes  sensitive  to  the  irritating  effect  of  these  toxins 
and  this  brings  on  suffering  of  various  kinds. 

The  suffering  is  first  noticed  as  pains  about  the 
abdomen,  head,  back,  and  lower  extremities.  The  longer 
the  taking  of  the  dose  is  deferred,  the  more  severe  this 
suffering  becomes.  Most  persons  who  are  habituated  to 
the  use  of  an  opiate  make  efforts  to  go  for  a  longer 
period  without  taking  the  accustomed  dose.  With  the 
system  in  the  toxic  state  usual  to  such  persons,  these 
efforts  at  abstinence  are  attended  by  suffering,  which 
always  forces  a  return  to  the  drug. 

After  a  patient  has  been  taken  off  an  opiate,  excess 
in  eating  causes  acute  toxemia,  and  that  is  attended  by 
suffering  very  similar  to  that  which  was  formerly  ex- 
perienced by  such  person  when  trying  to  do  without  the 
drug.  Excess  in  diet,  with  the  resulting  toxic  state 
incident  thereto,  revives  the  memory  of  this  former 
suffering,  and  this  unnerves  the  patient  to  such  a  degree 
that  he  does  not  bear  the  suffering  incident  to  such  toxic 
state  with  reasonable  fortitude.  Palliatives  for  relief 
are  early  sought  and  they  may  be  ruinous. 

The  fact  that  such  acute  toxic  state  brings  on  suffer- 
ing that  so  closely  simulates  the  suffering  from  chronic 
toxemia,  to  which  the  patient  was  formerly  exposed, 
makes  it  necessary  for  one  who  has  had  such  an  experi- 
ence to  be  doubly  guarded  about  his  diet. 

It  is  evident  that  all  persons  who  have  been  addicted 
to  narcotics  or  alcohol  should  live  on  a  low  calorie  diet, 
and  that  they  should  almost,  if  not  entirely,  exclude  red 
meat  from  their  diet  list. 

There  is  no  question  but  that  eating  lean  meat,  red 
meat,  in  the  quantities  usually  taken  greatly  overtaxes 


Diet  During  Convalescence.  263 

the  eliminating  organs  and  leaves  a  residue  of  toxic 
matter  in  the  system.  Meats  are  classed  by  all  physi- 
ologists as  a  stimulating  diet.  One  who  has  gone  to 
excess  in  the  use  of  stimulants  should  carefully  avoid  a 
stimulating  diet  as  well  as  all  other  forms  of  stimulation. 
Only  such  quantity  of  proteid  food  should  be  taken  as  is 
actually .  necessary.  Any  excess  results  in  intestinal 
toxemia,  with  its  attendant  dangers. 

Food  substances  are  divided  into  three  classes, 
known,  respectively,  as  proteids,  carbohydrates,  and 
hydrocarbons.  The  first  of  these  in  chemical  composi- 
tion consists  of  the  elements  carbon,  hydrogen,  oxygen, 
and  nitrogen.  The  second  class  contains  carbon,  hydro- 
gen, and  oxygen,  while  the  third  class  contains  only 
carbon  and  hydrogen. 

Food  of  the  three  classes  above  mentioned  is  neces- 
sary to  keep  the  body  in  perfect  condition,  but  these 
substances  should  be  taken  in  the  proportions  required 
by  the  system  and  not  merely  to  satisfy  a  cultivated 
appetite.  An  excess  of  proteid  food,  however,  is  much 
more  hurtful  than  an  excess  of  either  of  the  other 
classes.  It  has  been  shown  by  careful  physiological  ex- 
periments that  from  3%  to  4  ounces  of  proteid  food  per 
day  is  all  that  the  system  requires  and  is  all  that  it 
will  appropriate.  When  the  daily  intake  of  food  contains 
a  larger  quantity  of  proteid  than  that,  the  excess  under- 
goes putrefaction  in  the  intestine,  toxins  are  generated 
from  it,  and,  these  being  taken  into  the  blood  by  absorp- 
tion, interfere  with  the  proper  working  of  all  the  organs. 

The  best  results  are  obtained  in  convalescent  drug 
patients  by  arranging  their  meals  so  that  all  the  animal 
food,  food  consisting  principally  of  proteids,  is  taken  at 
one  meal,  the  principal  meal  of  the  day,  while  the  other 
two  meals  are  composed  of  vegetable  matter.  The 


264  Narcotic  Drug  Diseases  and  Allied  Ailments. 

animal  food,  especially  meat,  eggs,  and  sweet  milk,  is 
digested  in  the  stomach  and  requires  much  longer  time 
for  complete  digestion  than  food  of  either  of  the  other 
classes.  If  these  articles  or  either  of  them  are  taken  at 
one  meal  and  excluded  from  the  other  two  meals,  the 
stomach  is  not  taxed  with  so  many  hours'  work  as  it 
would  be  if  proteid  food  were  taken  at  each  of  the  three 
meals.  If  animal  food  rich  in  protein  be  taken  at  each 
of  the  three  meals,  the  stomach  is  called  upon  to  do  about 
nine  hours'  active  work  each  day.  The  stomach  is  not 
stronger  than  any  other  organ  in  the  body  or  than  the 
body  as  a  whole.  If  the  patient  was  called  upon  to  do 
nine  hours'  work  of  any  kind  per  day  he  would  not  be 
able  to  do  it.  Neither  should  the  stomach  be  expected 
to  work  so  many  hours.  All  the  proteid  food  that  is 
required  per  day  can  be  taken  at  one  meal;  it  is  much 
better  to  arrange  the  meals  so  that  that  will  be  done. 

The  carbohydrates  and  hydrocarbons  do  not  undergo 
digestion  in  the  stomach  or  particularly  tax  that  organ. 
They  are  macerated  and  dissolved  there,  but  are  digested 
by  the  pancreatic  and  hepatic  secretion,  with  which  they 
come  in  contact  in  the  duodenum  and  liver.  Their  diges- 
tion is  strictly  a  chemical  process  and  is  almost  instan- 
taneous. Their  digestion  taxes  the  digestive  organs 
much  less  than  does  the  digestion  of  proteids. 

The  following  is  an  ideal  dietary  list  for  a  convales- 
cent drug  patient  of  average  strength : — 

For  Breakfast. — An  orange  or  a  baked  apple,  a  bowl 
of  oatmeal  or  breakfast  food  with  sugar  and  cream,  one 
biscuit  with  butter,  or  two  pieces  of  toast  with  butter  and 
one  glass  of  buttermilk. 

For  Noon  Lunch. — A  plate  of  soup,  one  baked  potato 
with  butter,  a  glass  of  buttermilk,  one  piece  of  pie. 

For  6  p.m.  Dinner,  the  Principal  Meal. — Two  eggs ; 
two  individual  dishes  of  vegetables,  which  may  consist 


Appetite  a  "Creature"  of  Cultivation.  265 

of  either  baked  or  green  beans,  potatoes,  peas,  turnip 
salad,  spinach,  okra,  onions,  or  other  such  dish.  One 
glass  of  sweet  milk,  ice-cream  and  cake,  or  other  ordinary 
dessert. 

It  will  be  noticed  that  neither  meat,  coffee,  nor  tea  are 
included  in  this  list.  The  author  is  fully  convinced  that 
better  results  are  obtained  when  these  three  items  are 
entirely  excluded  from  the  patient's  diet  than  when  they 
are  taken. 

It  has  been  contended  that  the  appetite  is  a  safe 
guide  to  the  taking  of  food,  but  with  this  contention  the 
author  cannot  agree. 

Appetite  is  a  creature  of  cultivation  and  grows  by 
what  it  feeds  upon.  One  may  cultivate  an  appetite  for 
almost  anything  and  to  almost  any  degree.  Such  an  ap- 
petite often  is  of  such  impelling  nature  as  to  demand  the 
taking  of  excessive  quantities  of  food,  but  this  is  no 
index  to  what  the  system  requires  to  repair  the  waste  or 
build  up  tissue.  The  majority  of  people  are  completely 
enslaved  by  their  appetite  and  habitually  take  from  two 
to  four  times  as  much  food  as  their  systems  require. 

Appetite  that  has  not  been  abused  is  doubtless  a  fair 
index  to  the  needs  of  the  system,  but  the  appetite  of  the 
average  person,  perverted  by  cultivation  and  excess  as  it 
usually  is,  is  no  more  a  safe  guide  to  what  the  system 
requires  in  the  way  of  nourishment  than  feeling  is  a  safe 
guide  to  conduct  in  any  other  line.  Anyone  who  follows 
his  feelings  instead  of  his  judgment  is  led  into  innumer- 
able errors.  This  is  equally  true  of  one  who  eats  to 
satisfy  a  cultivated  or  perverted  appetite. 

When  the  appetite  has  not  been  abused,  or  an  artifi- 
cial appetite  created  by  overindulgence,  it  may  be  fol- 
lowed with  comparative  safety,  provided  the  food  to 
satisfy  it  be  taken  slowly  and  be  thoroughly  masticated. 


266  Narcotic  Drug  Diseases  and  Allied  Ailments. 

Rapid  eating,  with  incomplete  mastication  of  the  food, 
always  leads  to  the  taking  of  more  food  than  is  required 
before  the  appetite  is  satisfied. 

The  following,  by  Hancock,1  is  so  appropriate  in  this 
connection  that  the  author  takes  pleasure  in  quoting  it  in 
full:— 

"There  are  many  arguments  pro  and  con  as  to  the  use  of 
meat  in  the  dietary.  Chemically  we  know  that  meat  contains  no 
nutritive  properties  that  are  not  found  in  vegetable  foods.  'Con- 
servative' physiologists  contend  that  in  meat  we  have  all  of  the 
virtues  of  vegetables  in  a  form  more  easily  assimilable  in  the 
system.  The  retort  to  this  is  that  in  eating  meat  we  get  our 
nutriment  at  second  hand,  instead  of  at  first  hand,  as  in  eating 
vegetables,  and  that  meat  food  is  harmfully  stimulating.  The 
tide  of  physical  culture  is  setting  strongly  away  from  meat  as  an 
article  of  food. 

"Food  is  required  to  supply  in  the  body  material  for  repair 
of  tissue,  heat  with  which  to  maintain  life,  and  energy  for 
muscular  exertion.  Chemistry  has  been  made  to  demonstrate 
that  all  foods  may  be  divided  under  three  important  heads : — 

"Protein. — This  comprises  the  chemical  element  in  food, 
which,  with  mineral  salts,  is  used  to  build  up  the  tissues  of  the 
body.  The  proteids  are  nitrogenous  foods,  that  is,  nitrogen 
enters  into  their  composition.  Examples  of  the  proteids  are 
casein,  myosin,  gluten,  legumin.  Among  the  nitrogenous  foods 
are  the  albuminoids,  of  which  gelatin  is  an  example.  The  pro- 
teids, water,  and  mineral  salts  will  maintain  life  without  the  aid 
of  the  two  kinds  of  food  that  are  now  to  be  enumerated. 

"Carbohydrates. — Starch  and  the  various  sugars. 

"Fats. — Vegetable  oils,  animal  fat,  butter,  etc. 

"While  the  proteids  not  only  build  up  tissue  (with  the  aid  of 
water  and  mineral  salts),  but  also  supply  some  heat  and  energy, 

1  "The  Physical  Culture  Life,"  Hancock.  G.  P.  Putnam's  Sons, 
New  York. 


Diet,  Proper  Proportions  of.  267 

it  is  the  direct  work  of  the  carbohydrates  and  fats,  which  do  not 
build  up  tissue,  to  supply  heat  and  energy.  This  the  carbohy- 
drates do  directly,  while  fats  are  stored  up  in  the  system  to  con- 
serve heat  and  energy  until  they  are  needed.  While  proteids  will 
furnish  heat  and  energy  as  well  as  tissue,  the  ingestion  of  carbohy- 
drates and  fats  saves  much  of  what  would  be  otherwise  a  drain 
upon  the  proteid-tissue  supply. 

"The  ideal  diet,  then,  must  contain  sufficient  of  the  proteids 
to  repair  all  waste  of  tissue  and  to  build  up  increased  amounts 
of  tissue  when  needed,  and  enough  of  the  carbohydrates  and  fats 
to  meet  all  demands  for  heat  and  energy  and  to  store  up  a  reserve 
in  the  body  until  demanded.  It  is  important,  therefore,  that 
proteids,  carbohydrates,  and  fats  should  be  taken  in  the  proper 
proportion. 

"What  are  these  proper  proportions?  The  most  important 
elements  supplied  by  the  foods  are  the  nitrogen  in  the  proteids, 
and  the  carbon  in  the  carbohydrates  and  the  fats. 

"Physiologists  have  been  wont  to  contend  until  very  recently 
that  about  20  grammes  of  nitrogen  are  needed  in  the  system  in  the 
twenty-four  hours.  As  protein  is  16  per  cent,  nitrogen,  this 
would  mean  the  daily  intake  of  about  125  grammes  of  protein. 
An  ounce  is  equal  in  weight  to  about  30  grammes,  so  that  a  trifle 
under  4  ounces  of  protein  would  be  the  amount  needed  under  this 
rule.  In  the  case  of  proteid  foods  averaging  25  per  cent,  of 
protein,  it  would  mean  the  daily  consumption  of  16  ounces  of 
such  food. 

"According  to  the  same  standards,  about  320  grammes  (n 
ounces)  of  carbon  in  proteids  or  in  carbohydrates  and  fats  are 
needed  daily  in  the  food.  As  the  protein  is  about  one-half  carbon, 
62  of  these  320  grammes  are  supplied  in  the  proteid  intake  of 
food,  leaving  260  grammes  of  carbon  to  be  supplied  by  carbohy- 
drates and  fat,  and  this,  according  to  the  ordinary  standard, 
is  furnished  in  the  proper  proportion  if  50  grammes  a  day  of  fat 
be  eaten  and  500  grammes  of  carbohydrate  food. 


268  Narcotic  Drug  Diseases  and  Allied  Ailments. 

"Now,  for  determining  the  fuel  value  of  food,  a  standard  of 
heat  is  employed  that  is  known  as  the  large  calorie.  This  calorie 
represents  the  amount  of  heat  necessary  to  raise  I  pound  of  water 
4°  Fahrenheit  in  temperature.  Now,  the  daily  diet  just  men- 
tioned would  supply  about  3025  calories  of  fuel  material  for 
heat  and  energy,  and  this  is  close  to  the  more  commonly  accepted 
standards  of  dietary  needs. 

"The  following  is  given  by  Hutchinson  as  a  sample  of  a 
day's  food  in  the  mixed  diet:  Beef,  8  ounces;  salt  mackerel,  4 
ounces ;  two  eggs,  3  ounces ;  butter,  2%  ounces ;  cheese,  i  ounce ; 
milk,  i  pint ;  potatoes,  8  ounces ;  rice,  2  ounces ;  bread,  9  ounces ; 
sugar,  i%  ounces.  This  makes  55  ounces  of  food,  or  about  3% 
pounds,  again  the  common  standard  of  a  day's  food  for  an  adult 
person.  The  fuel  yield  in  calories  is  3205. 

"In  order  that  the  reader  may  do  some  figuring  for  himself, 
if  so  inclined,  and,  in  any  event,  to  satisfy  a  very  natural  curiosity 
regarding  the  compositions  of  the  ordinary  foods  and  their  fuel 
values,  tables  are  presented  herewith  that  have  been  gleaned  from 
a  report  furnished  to  the  U.  S.  Department  of  Agriculture  by 
Professor  Atwater.  The  data  given  are  for  the  foods  in  the 
condition  in  which  they  are  purchased.  'Refuse'  covers  any 
waste  due  to  bone,  shells,  trimming,  allowance  for  cores,  peels, 
inedible  seeds,  etc.  The  'ash'  is  that  portion  of  a  food  which  is 
not  acted  upon  in  the  digestive  tract,  and  which  leaves  the  body 
just  as  it  enters.  Much  of  the  water  is  lost  in  cooking  some  of 
the  foods.  In  meats,  cooking  brings  about  a  loss,  both  of  fat 
and  of  water. 

"One  example  will  indicate  the  method  of  making  computa- 
tions from  the  following  food  tables.     Suppose  that  a  pound  ( 16 
ounces)  of  freshly  gathered  chestnuts  be  weighed  out;  then,  by 
the  use  of  the  tables*,  we  are  able  to  get  at  these  results. 
1 6  ounces  X  0.052  =  0.832  ounces  protein. 

0.832  ounces  protein  X  0.16  =  0.133  ounces  of  nitrogen. 
1 6  ounces  X  0.045  =  °-72  ounces  of  fat. 
16  ounces  X  0.354  =  5.664  ounces  of  carbohydrate. 

Fuel  value  in  a  pound  of  chestnuts  =  915  calories." 


Food  Values  in  Calories. 


269 


ANIMAL  AND  VEGETABLE  FOOD  VALUKS. 


Refuse. 
Per  cent. 

Water. 
Per  cent. 

Protein. 
Per  cent. 

Pat. 
Per  cent. 

Carbohydrate. 
Per  cent. 

Ash. 
Percent. 

Fuel  value  per 
pound  in  calories. 

BEEF 
Chuck,  ribs  

16.3 

52.6 

15.5 

15.0 

0.8 

910 

Flanks  

10.2 

54.0 

17.0 

19.0 

0.7 

1105 

Loin  

13.3 

52.5 

17.1 

17.5 

0.9 

1025 

Porterhouse  steak 

12  7 

52.4 

19.1 

17.9 

0  8 

1100 

Sirloin  steak  

12.8 

54.0 

16.5 

16.1 

0.9 

975 

Neck  

27.6 

45.9 

14.5 

11.9 

0.7 

1165 

Ribs  

20  8 

43.8 

13  9 

21.2 

0.7 

1135 

Round  . 

7.2 

60.7 

19  0 

12.8 

1.0 

890 

Rump  . 

20  7 

45.0 

13  8 

20.2 

0.7 

1090 

Corned  beef 

8.4 

49.2 

14.3 

23.8 

4  6 

1245 

Tongue,  pickled 

6  0 

58.9 

11  9 

19.2 

4.3 

1010 

Dried  or  salted  ,           .... 

4.7 

53.7 

26  4 

6.9 

8.9 

790 

Canned  corned  beef 

51.8 

26.3 

18.7 

4.0 

1270 

VEAL 
Breast  

21.3 

52.0 

15.4 

11.0 

0.8 

745 

Leg;  .  . 

14.2 

60.1 

15.5 

7.9 

0.9 

625 

Fore  quarter  

24.5 

54.2 

15.1 

6.0 

0.7 

535 

Hind  quarter  

20.7 

56.2 

16.2 

6.6 

0.8 

580 

MUTTON 
Flank  

9  9 

39  0 

13  8 

36.9 

0.6 

1770 

Hind  leg  

18.4 

51  2 

15  1 

14.7 

0.8 

890 

Loin  chops  

16  0 

42  0 

13  5 

28  3 

0.7 

1415 

Fore  quarter  

21  2 

41  6 

12  3 

24.5 

0.7 

1235 

Hind  quarter  (without  tal- 
low)   

17  2 

45  4 

13  8 

23.2 

0.7 

1210 

LAMB 
Breast  

19.1 

45.5 

15  4 

19.1 

0.8 

1075 

Hind  leg  

17  4 

52  9 

15  9 

13  6 

0  9 

860 

PORK 
Ham  

10  7 

48  0 

13  5 

25  9 

0.8 

1320 

Loin  chops  

19  7 

41  8 

13  4 

24.2 

0.8 

1245 

Shoulder  

12  4 

44  9 

12  0 

29.8 

0.7 

1450 

Tenderloin  

66  5 

18  9 

13  0 

1.0 

895 

Smoked  ham  

13  6 

34  8 

14  2 

33.4 

4.2 

1635 

Salt  pork  

7  9 

1  9 

86  2 

3.9 

3555 

Smoked  bacon  

7  7 

17  4 

9  1 

62  2 

4.1 

2715 

SAUSAGE 
Bologna  

3.3 

55  2 

18.2 

19.7 

3.8 

1155 

Pork  

39.8 

13.0 

44.2 

1.1 

2.2 

2075 

Frankfurt  

57.2 

19.6 

18.6 

1.1 

3.4 

1155 

POULTRY 
Chicken,   broilers  

41  6 

43  7 

12.8 

11.4 

0.7 

305 

Fowl  

25.9 

47  1 

13.7 

12.3 

0.7 

765 

270  Narcotic  Drug  Diseases  and  Allied  Ailments. 


ANIMAL  AND  VEGETABLE:  FOOD  VALUES— Continued. 


Refuse. 
Per  cent. 

.  o 

U   0 

*  o 
'S  <? 

£i£ 

Protein. 
Per  cent. 

Pat. 
Per  cent. 

Carbohydrate. 
Pei  cent. 

Ash. 
Per  cent. 

Fuel  value  per 
pound  in  calories. 

POULTRY—  Concluded. 
Turkey          

22.7 

42.4 

16  1 

18.4 

0  8 

1060 

Hens'  eggs  

11.2 

65.5 

13.1 

9.3 

0.9 

635 

DAIRY  PRODUCTS 
Butter  

11.0 

1.0 

85.0 

3.0 

3410 

Whole  milk  

87.0 

3.3 

4.0 

5.0 

0.7 

310 

Skim  milk  

90.5 

3.4 

0.3 

5.1 

0.7 

165 

Buttermilk  

91.0 

3.0 

0.5 

4.8 

0.7 

160 

Condensed  milk  

26.9 

8.8 

8.3 

54.1 

1.9 

1430 

Cream  

74.0 

2.5 

18.5 

4.5 

0.5 

865 

Cheddar  cheese  

27.4 

27.7 

36.8 

4.1 

4.0 

2075 

Cream  cheese  

34.4 

25.9 

33.7 

2.4 

3.8 

1885 

FISH 
Cod,  dressed  

29  9 

58.5 

11.1 

0.2 

0.8 

220 

Halibut,  steaks  or  sections 

17.7 

61.9 

15.3 

4.4 

0.7 

475 

Whole  mackerel  

44  7 

40  4 

10.2 

4.2 

0.7 

370 

Yellow  perch,  dressed  .  .  . 

55  1 

50  7 

12.8 

0.7 

0.9 

275 

Whole  shad  

50  1 

35  2 

9.4 

4.8 

0.7 

380 

Shad  roe  

71.2 

20.9 

3.8 

2.6 

1.5 

600 

Salt  cod  

24  9 

40.2 

16.0 

0.4 

18.5 

325 

Smoked  herring  

44.4 

19.2 

20.5 

8.8 

7.4 

755 

Canned  salmon  

63  5 

21.8 

2.1 

2.6 

915 

Canned  sardines  

5.0 

53.6 

23.7 

12.1 

5.3 

950 

Oysters  (without  shells).  . 
Clams  (without  shells)  .  .  . 

0.0 

88.3 
80  8 

6.0 
10.6 

1.3 
1.1 

3.3 
5.2 

1.1 
2.3 

225 
340 

Crabs  

52.4 

36.7 

7.9 

0.9 

0.6 

1.5 

200 

Lobsters  

61  7 

30.7 

5.9 

0.7 

0.2 

0.8 

145 

FLOUR,  MEAL,  ETC. 
Whole-wheat  flour  

11.4 

13.8 

1.9 

71.9 

1.0 

1650 

Graham  flour  

11.3 

13.3 

2.2 

71.4 

1.8 

1645 

Wheat  flour  (roller  proc- 
ess )  

12.0 

11.4 

1.0 

71.5 

0.5 

1635 

Macaroni,  vermicelli  

10.3 

13.4 

0.9 

74.1 

1.3 

1645 

Wheat  breakfast  food  .... 

9.6 

12.1 

1.8 

75.2 

1.3 

1680 

Buckwheat  flour  

13.6 

6.4 

1.2 

77.9 

0.9 

1605 

Rye  flour  

12.9 

6.8 

0.9 

78.7 

0.7 

1620 

Cornmeal  

12.5 

9.2 

1.9 

75.4 

1.0 

1635 

Oat  breakfast  food  

7.7 

16.7 

7.3 

66.2 

2.1 

1800 

Rice  

12.3 

8.0 

0.3 

79.0 

0.4 

1620 

Tapioca  

11.4 

0.4 

0.1 

88.0 

0.1 

1650 

Starch  

90.0 

1675 

BREAD  AND  CRACKERS 
White  bread  

35.3 

35.3 

9.2 

1.3 

53.1 

1.1 

1200 

Brown  bread  

43.6 

5.4 

1.8 

47.1 

2.1 

1040 

Graham  bread  

35.7 

8.9 

1.8 

52.1 

1.5 

1195 

Food  Values  in  Calories. 


271 


ANIMAL  AND  VEGETABLE  FOOD  VALUES— Continued. 


2 

rt 

•s  . 

VI 

£ 

t-i°C 
4>  O 

a-a 

O  '-> 
3  a 

Refuse. 
Per  cen 

Water. 
Per  cen 

Protein. 
Per  cen 

Fat. 
Per  cent 

Carbohi 
Per  cen 

a. 
• 
.  o 
fi  u, 

%& 

Fuel  va 
pound  1 

BREAD  AND  CRACKERS— 

Concluded. 

Whole-wheat  bread  

38.4 

9.7 

0.9 

47.7 

1.3 

1130 

Rye  bread       ...         ... 

35.7 

9.0 

0.6 

53.2 

1.5 

1170 

Cream  crackers 

6.8 

9.7 

12.1 

79.7 

1.7 

1925 

Oyster  crackers  

4.8 

11.3 

10.5 

70.5 

2.9 

1910 

Soda  crackers  

5.9 

9.8 

9.1 

73.1 

2.1 

1875 

SUGARS,  ETC. 
Molasses  

70.0 

1225 

Plain  candy  

96.0 

1680 

Honey  

81.0 

1420 

100.0 

1750 

71.4 

1250 

VEGETABLES 
Dried  beans  

12.6 

22  5 

1  8 

59.6 

3.5 

1520 

Lima  beans,  shelled  

68.5 

7.1 

0.7 

22.0 

1.7 

540 

String  beans  

7.0 

83.0 

2  1 

0  3 

6.9 

0.7 

170 

Beets  

20.0 

70.0 

1  3 

0  1 

7.7 

0  9 

160 

Cabbage  

15  0 

77.7 

1  4 

0  2 

4.8 

0  9 

115 

Celery  

20  0 

75.6 

0  9 

0  1 

2.6 

0  8 

65 

Green  sweet  corn  (edible 
portion)  

75.4 

3  1 

1  1 

19.7 

0.7 

440 

Cucumbers  

15  0 

81.1 

0  7 

0  2 

2.6 

0  4 

65 

Lettuce  

15  0 

80.5 

1  0 

0  2 

2.5 

0.8 

65 

Mushrooms     

88.1 

3  5 

0  4 

6.8 

1.2 

85 

Onions  

10  0 

78.9 

1  4 

0  3 

8.9 

0.5 

190 

Parsnips  

20.0 

66.4 

1  3 

0  4 

10.8 

1.1 

230 

Dried  peas  

9.5 

24.0 

1.0 

62.0 

2.9 

1565 

Shelled  peas  

74.6 

7.0 

0.5 

16.9 

1.0 

440 

Potatoes  

20  0 

62  6 

1  8 

0  1 

14.7 

0  8 

295 

Rhubarb  

40  0 

56  6 

0  4 

0  4 

2  2 

4  4 

60 

Sweet  potatoes  

20.0 

55.2 

1.4 

0.6 

21.9 

0.9 

440 

Spinach  

0.0 

92.3 

2.1 

0.3 

3.2 

2.1 

95 

Squash  

50.0 

44.2 

0.7 

0.2 

4.5 

0.4 

100 

Tomatoes  

94.3 

0.9 

0.4 

3.9 

0.5 

100 

Turnips  

30.0 

62.7 

0.9 

0.1 

5.7 

0.6 

120 

CANNED  VEGETABLES 
Baked  Beans  

68.9 

0.9 

2  5 

19.6 

2  1 

555 

Peas  

85.3 

3.6 

0.2 

9.8 

1  1 

235 

Green  corn  

76.1 

2.8 

1.2 

19.0 

0  9 

430 

Succotash  

75.9 

3.6 

1.0 

18.6 

0.9 

425 

Tomatoes  

94.0 

1.2 

0.2 

4  0 

0  6 

95 

FRESH  FRUITS 
Apples  .  . 

25.0 

63.3 

0.3 

0.3 

10.8 

0  3 

190 

Bananas  

35.0 

48.9 

0.8 

0.4 

14.3 

0.6 

260 

Grapes  

25.0 

58.0 

1.0 

1.2 

14.4 

0.4 

295 

272  Narcotic  Drug  Diseases  and  Allied  Ailments. 


ANIMAL  AND  VEGETABLE  FOOD  VALUES—  Concluded. 


Refuse. 
Per  cent. 

Water. 
Per  cent. 

Protein. 
Per  cent. 

Fat. 
Per  cent. 

Carbohydrate. 
Per  cent. 

Ash. 
Per  cent. 

Fuel  value  per 
pound  in  calories. 

FRESH  FRUITS  —  colluded. 
Lemons  

30.0 

62.5 

0  7 

0.5 

5.9 

0  4 

125 

Muskmelons  

50.0 

44.8 

0.3 

4.6 

0.3 

80 

Oranges  

27.0 

63.4 

0.6 

0.1 

8.5 

0.4 

150 

Pears  

10.0 

76.0 

0.5 

0.4 

12.7 

0.4 

230 

Raspberries  

85.8 

1.0 

12.6 

0.6 

220 

Strawberries        

5  0 

85.9 

0  9 

0.6 

7  0 

0  6 

150 

Watermelons  

59.4 

37.5 

0.2 

0.1 

2.7 

0.1 

50 

DRIED  FRUITS 
Apples  

28.1 

1  6 

2.2 

66.1 

2  0 

1185 

Apricots  

29.4 

4  7 

1.0 

62.5 

2.4 

1125 

Dates  

10.0 

13.8 

1.9 

2.5 

7.6 

1.2 

1275 

Figs  .. 

18.8 

4.3 

0.3 

74.2 

2.4 

1280 

Raisins  

10.0 

13.1 

2.3 

3.0 

68.5 

3.1 

1265 

NUTS 
Almonds  

45.0 

2.7 

11.5 

30.2 

9.5 

1  1 

1515 

Brazil  nuts  

49.6 

2.6 

8  6 

33.7 

3.5 

2  0 

1485 

Butternuts  

86.4 

0.6 

3.8 

8.3 

0.5 

0  4 

385 

Chestnuts,  fresh  

16.0 

37.8 

5.2 

4.5 

35.4 

1.1 

915 

Chestnuts,  dried  

24.0 

4.5 

8.1 

5.3 

56.4 

1.7 

1385 

Cocoanuts  

48.8 

7.2 

2.9 

25.9 

14.3 

0.9 

1295 

Cocoanuts,  prepared  

3.5 

6.3 

57.4 

31.5 

1.3 

2865 

Filberts  

52.1 

1.8 

7.5 

31.1 

6.2 

1.1 

1430 

Hickory  nuts  

62.2 

1.4 

5.8 

25.5 

4.3 

0.8 

1145 

Pecans  

53.2 

1.4 

5.2 

33.3 

6  2 

0  7 

1465 

Peanut  

24.5 

6.9 

19.5 

29.1 

18  5 

1  5 

1775 

Pinon      

40.6 

2.0 

8.7 

36.8 

10.2 

1.7 

1730 

Walnuts,  black  

74.1 

0.6 

7.2 

14.6 

3.0 

0.5 

730 

Walnuts,  English  

58.1 

1.0 

6.9 

26.6 

8.6 

0.6 

1250 

"In  contrast  to  the  common  standards  of  diet,  which  call  for 
20  grammes  of  nitrogen  daily  in  the  food  and  the  total  fuel 
value  of  from  3000  to  3500  calories,  let  us  take  the  case  of 
Horace  Fletcher,  an  American  who  seems  destined  to  prove  the 
new  Moses  of  nutrition.  Years  ago  ill  health  forced  Mr. 
Fletcher,  once  a  college  athlete,  to  devote  serious  attention  to  his 
health.  He  chose  to  regain  health  through  food,  pure  air,  and 
exercise.  His  experiments  with  himself  led  him  to  the  adoption 
of  what  most  people  would  term  a  starvation  diet — but  he  thor- 


Sample  Meals.  273 


oughly  masticated  his  seemingly  small  quantity  of  food.  Mr. 
Fletcher  has  demonstrated  his  ability  to  maintain  perfect  health 
and  normal  activity  on  a  diet  that,  in  a  course  of  experimenting, 
amounted  to  %T  of  an  average  dietary  of  to-day. 

"While  under  observation  at  Yale  College  Mr.  Fletcher  sub- 
sisted for  several  days  on  a  diet  that  supplied  him  with  a  daily 
average  of  44.9  grammes  of  proteids,  38  grammes  of  fat,  and 
253  grammes  of  carbohydrate  and  with  a  daily  fuel  average  of 
1606  calories.  Anderson,  the  University's  physical  director,  kept 
Mr.  Fletcher  at  the  same  kind  of  hard  exercising  work  as  that 
undergone  by  the  varsity  crew  in  training.  Anderson  had  this  to 
say  of  his  observations  of  the  experiment: — 

"  'My  conclusion,  given  in  condensed  form,  is  this :  Mr. 
Fletcher  performs  this  work  with  greater  ease  and  with  fewer 
noticeable  bad  results  than  any  man  of  his  age  and  condition  I 
have  ever  worked  with.' 

"Not  long  ago  a  squad  of  regular  army  soldiers  was  experi- 
mented upon  at  Yale  along  the  lines  of  Mr.  Fletcher's  dietary 
practices.  The  proposal  to  cut  down  the  supply  of  food  was  so 
awesome  to  some  of  the  soldiers  that  they  deserted,  but  those  who 
acted  upon  Mr.  Fletcher's  'low-diet'  plan  performed  at  the  same 
time  hard  work  in  the  Yale  Gymnasium,  and  came  out  of  the 
several  weeks'  experiment  in  splendid  trim.  Yet  here  is  a  sample 
of  the  day's  food  for  one  of  the  men : — 

"Breakfast.  —  Soft  oatmeal,  150  grammes;  milk,  100 
grammes;  sugar,  30  grammes;  butter,  10  grammes;  bread,  30 
grammes;  i  cup  of  coffee;  total,  350  grammes. 

"Dinner. — Baked  macaroni  and  cheese,  200  grammes ;  stewed 
tomatoes,  200  grammes ;  bread,  50  grammes ;  tapioca  peach  pud- 
ding, 150  grammes;  coffee;  total,  350  grammes. 

"Supper. — French  fried  potato,  100  grammes;  fried  bacon, 
20  grammes;  bread,  75  grammes;  jam,  75  grammes;  tea;  total, 
350  grammes. 

"This,  according  to  Professor  Crittenden,  in  charge  of  the  ex- 
periment, meant  intake  in  a  day  of  7.282  grammes  of  nitrogen  and 

18 


274  Narcotic  Drug  Diseases  and  Allied  Ailments. 

a  total  fuel  value  of  1824  calories.  When  it  is  remembered  that 
about  30  grammes  equal  an  ounce,  it  will  be  understood  upon 
how  small  a  quantity  of  food  health  and  activity  were  maintained. 

"Rabagliati,  one  of  England's  famous  cancer  specialists,  and 
a  recognized  expert  in  nutrition,  has  estimated  that  about  12  to 
24  ounces  of  food,  depending  upon  weight,  condition,  and  activity 
of  the  individual  subject,  represent  the  sanest  and  safest  quantity 
of  food  for  the  adult  human  being. 

"In  closing  this  chapter,  it  may  be  added,  by  way  of  general 
statement,  that  the  average  conclusion  of  recent  investigators  in 
the  field  of  'low  dietaries'  is  that  even  those  who  pride  themselves 
upon  their  very  moderate  eating  consume  every  day  from  two 
to  three  times  as  much  food  as  they  need,  and  that  every  morsel 
of  food  taken  in  excess  of  what  is  really  requisite  is  a  detriment 
to  health,  with  no  compensating  advantage  possible." 


CHAPTER  XIII. 
PROGNOSIS. 

THE  prognosis  in  any  disease  depends  very  much 
upon  the  thoroughness  with  which  the  treatment  is 
carried  out.  That  is  true  with  the  narcotic  drug  addic- 
tions, as  well  as  with  other  diseases.  Therefore,  in 
devising  a  course  of  treatment  the  author  endeavored  to 
make  the  same  as  complete,  and  as  fully  in  accord  with 
laws  of  physiology  and  with  the  general  principles  of 
medicine,  as  possible. 

The  author  has  often  been  asked  the  question: 
"What  per  cent,  of  patients  cured  remains  well?"  No 
direct,  unqualified  answer  can  be  made  to  that  question. 
The  permanency  of  cure  in  drug  addiction  depends  upon 
many  factors,  but  the  principal  one  is  the  patient  himself. 
Much  also  depends  upon  the  manner  in  which  the  addic- 
tion was  formed. 

In  order  to  estimate  with  any  degree  of  certainty  the 
probability  of  permanency  of  cure  in  any  given  case,  it  is 
necessary  to  take  into  consideration  the  character  and 
habits  of  the  individual  before  the  addiction  was  formed, 
the  manner  in  which  the  addiction  was  formed,  the  pur- 
poses of  life  which  dominate  him,  and  the  experiences  to 
which  he  has  been  subjected  since  beginning  the  use  of 
the  drug,  including  the  number,  kind,  and  results  of 
treatment  he  has  taken  for  the  addiction.  With  this  data 
at  hand,  the  probability  of  permanency  of  cure  can  be 
foretold  with  a  fair  degree  of  accuracy. 

If  the  use  of  the  drug  was  taken  up  as  a  dissipation, 
the  chance  of  permanent  cure  is  very  slight,  since  the 
use  of  the  drug  would  increase  rather  than  overcome 

(275) 


276  Narcotic  Drug  Diseases  and  Allied  Ailments. 

such  a  tendency  to  dissipate,  and,  since  the  tendency  to 
dissipate  which  originally  led  to  the  use  of  the  drug 
would  still  exist,  and  would  likely  be  strengthened  rather 
than  weakened  by  the  use  of  the  drug,  that  tendency 
would  likely  control  the  patient  and  lead  again  to  the  use 
of  the  drug. 

However,  even  in  these  unpromising  cases,  if  the 
slavery  from  the  use  of  the  drug  has  effected  such  a 
change  in  the  mental  attitude  of  the  drug  user  as  to  over- 
come this  bent  toward  dissipation,  then  a  permanent  cure 
may  be  effected,  even  in  some  of  these  cases,  notwith- 
standing the  fact  that  the  use  of  the  drug  was  begun  as  a 
dissipation.  It  takes  a  calamity,  such  as  years  of  drug 
slavery,  to  bring  some  people  to  their  senses  and  cause 
them  to  think.  If  the  abject  slavery  brought  about  by 
the  use  of  a  drug  shall  have  taught  such  a  dissipated  one 
the  lesson  and  impressed  that  lesson  strongly  enough  to 
influence  his  future  conduct  even  in  these  unpromising 
cases  sometimes  a  permanent  cure  may  be  made. 

But  not  more  than  15  per  cent,  of  drug  habitues  enter 
upon  the  use  of  a  drug  as  a  dissipation,  or  as  a  sequence 
of  other  forms  of  dissipation.  The  remaining  85  per 
cent,  are  usually  brought  into  the  addiction,  either  inad- 
vertently or  accidentally. 

Probably  75  per  cent,  of  all  laymen  addicted  to  the 
use  of  drugs  owe  their  addiction  to  the  indiscreet  or 
necessary  use  of  opiates  by  physicians.  Protracted  pain- 
ful ailments  force  upon  them  a  condition  which  they  are 
unable  afterward  to  throw  off  by  their  own  efforts. 
These  victims  of  the  drug  are  never  willing  slaves ;  they 
are  rebels  throughout  the  entire  period  of  subjugation, 
and  they  always  hope  and  look  forward  to  a  time  when 
they  may  be  set  at  liberty. 

When  a  patient  of  that  class  is  really  cured,  when  put 
back  on  his  feet  free  from  the  dominating  influence  of 


Relapse  Not  Likely.  Ill 


narcotics  and  given  a  fair  chance  to  live  without  them, 
he  rarely  returns  to  their  use;  in  fact,  the  author's  ex- 
perience with  such  persons  is  that  there  is  little,  if  any, 
tendency  to  relapse. 

There  is  this  difference,  however;  these  patients  do 
not  bear  pain  well,  that  is,  the  continued  use  of  the  drug 
and  the  suffering  that  at  times  occurs  from  it  reduce 
their  tolerance  of  pain.  Therefore,  if  any  severe  painful 
ailment  overtakes  them  after  they  are  freed  from  the 
addiction,  and  it  becomes  necessary  for  them  to  use 
opiates,  even*  for  a  few  days,  the  addiction  is  soon  re- 
formed. They  become  entirely  dependent  upon  the  drug 
in  very  much  less  time  than  it  took  for  the  addiction  to 
become  confirmed  in  the  first  instance. 

It  is  essential  to  the  permanency  of  cure  in  any  case 
that  the  cause  which  originally  led  to  the  addiction  be 
removed.  If  this  was  a  chronic  painful  ailment  which 
still  exists,  then  it  may  not  be  expected  that  the  addiction 
can  be  cured  permanently  without  the  cure  of  the  painful 
ailment  upon  which  it  depends. 

This  ailment  should  be  treated  in  connection  with  the 
addiction,  or  immediately  following  it,  to  the  end  that 
the  patient  may  not  be  called  upon  to  stand  the  suffering 
from  it  without  the  relief  which  he  formerly  obtained 
from  the  drug. 

If  the  addiction  was  taken  up  inadvertently,  as  in 
case  of  a  physician  using  a  drug  to  prolong  his  working 
hours,  he  must  have  become  so  impressed  with  the 
gravity  of  his  error  as  to  lead  him  to  entirely  renounce 
such  a  course  and  to  give  up  the  use  of  all  stimulants. 
There  can  be  no  compromise  in  this  matter  without 
failure. 

The  use  of  alcoholic  beverages,  even  of  the  mildest 
kind,  will  inevitably  lead  to  a  resumption  of  the  narcotic. 


278  Narcotic  Drug  Diseases  and  Allied  Ailments. 

Many  authors  still  advise  the  use  of  alcoholic  liquors  in 
the  after-treatment  of  these  cases,  but  no  more  fatal 
error  was  ever  made. 

No  man  who  has  been  addicted  to  the  use  of  mor- 
phine can  afterward  use  alcohol  in  moderation.  If  he 
uses  it  at  all  in  any  form  he  is  sure  to  go  to  excess  and 
this  excess  leads  to  his  sobering  up  by  returning  to  the 
use  of  the  opiate.  If  he  would  continue  to  be  free  from 
drug  slavery,  he  must  give  up  stimulants  of  all  kinds  and 
live  a  sober,  discreet  life. 

The  almost  universal  failure  to  permanently  cure 
drug  addiction  by  the  methods  of  treatment  heretofore 
in  vogue  is  fully  accounted  for  when  we  consider  the 
matter  from  a  dispassionate  and  impartial  point  of  view. 

Classification  of  the  condition  as  one  having  no 
pathology,  as  a  mere  appetite  or  vice,  removed  all  basis 
for  rational  therapeutic  endeavor.  Regarding  the 
patient  as  a  fiend,  a  pervert,  one  devoid  of  principle  and 
moral  purpose,  placed  such  a  barrier  between  him  and 
his  physician  that  no  common  ground  could  be  found 
upon  which  to  establish  the  confidential  relations  which 
were  essential  to  success.  The  failure  to  recognize  the 
widespread  function  derangement  present  as  patho- 
logical factors  to  be  met  by  therapeutic  measures  led  the 
physician  into  the  erroneous  conclusion  that  the  with- 
drawal of  the  drug  was  all  that  was  necessary  to  con- 
stitute a  cure. 

In  endeavoring  to  carry  out  even  this  mistaken  idea 
of  treatment,  the  gradual-reduction  method  was  usually 
adopted.  This  was  simply  a  torturing  process  by  which 
the  patient  was  starved  off  of  the  drug,  leaving  him  in  a 
far  more  wretched  condition  than  before  the  beginning 
of  treatment. 

During  this  long-drawn-out  siege  of  suffering  the 
patient's  mind  dwelt  almost  constantly  upon  the  drug 


From  Morphinist  to  Morphinomaniac.  279 

and  he  longed  for  the  relief  which  it  alone  could  give 
him.  This  one  thought  occupied  his  mind  to  the  exclu- 
sion of  everything  else.  The  urgent  demand  for  the 
drug  to  relieve  the  intense  suffering  due  to  the  toxic 
condition  of  his  system  was  so  great  that  the  patient 
could  think  of  nothing  else. 

This  intense  physical  and  mental  strain  converted  the 
patient  from  a  simple  drug  user,  a  morphinist,  into  a 
morphinomaniac.  The  morphinist  continues  to  use  the 
drug  because  his  physical  condition  demands  it,  and  he 
will  rarely  return  to  its  use  if  that  physical  demand  is 
overcome. 

On  the  other  hand,  the  morphinomaniac  is  controlled 
by  his  mental  condition  rather  than  by  his  physical.  No 
matter  how  perfectly  he  may  be  freed  from  all  physical 
necessity  for  the  drug,  if  the  mania  is  not  corrected, 
he  will  resume  its  use  as  soon  as  he  is  given  liberty. 

He  must  be  cured  mentally,  as  well  as  physically ;  but 
instead  of  the  gradual-reduction  method  of  treatment 
doing  that,  it  is  the  most  effective  means  of  perpetuating 
the  mania  that  the  ingenuity  of  man  could  have  devised. 

There  is  no  question  but  that  the  employment  of  the 
reduction  method  of  treatment  has  done  many,  many 
times  more  to  render  these  helpless  victims  incurable 
than  it  has  done  toward  curing  them.  The  failure  neces- 
sarily growing  out  of  the  employment  of  this  unnatural 
and  unscientific  process  has  done  more  to  damage  the 
cause  of  drug  users  with  the  profession  and  the  public 
than  all  other  influences  combined.  It  has  done  much  to 
create  the  impression  that  these  victims  are  hopelessly 
incurable,  that  they  have  no  desire  to  be  cured,  and  would 
not  remain  well  if  cured. 

This  process  not  only  failed  to  correct  the  physical 
derangements  present,  but  impaired  the  mind  to  such  a 


280  Narcotic  Drug  Diseases  and  Allied  Ailments. 

degree  that  the  patient  no  longer  acted  from  reason,  but 
was  dominated  by  a  mania  which  always  led  him  in  a 
wrong  direction.  Notwithstanding  the  fact  that  he  was 
not  cured,  either  mentally  or  physically,  he  was  never- 
theless expected  to  stand  on  his  feet  and  be  a  man.  Be- 
cause of  his  inability  to  do  this  he  has  been  stigmatized 
as  a  fiend,  a  pervert,  one  wholly  given  over  to  a  vicious 
appetite. 

This  verdict  is  as  unreasonable  as  it  is  cruel  and 
unjust.  One  should  not  be  thus  condemned  until  he  has 
been  given  a  reasonable  chance;  he  should  not  be  ex- 
pected to  remain  well  until  he  has  really  been  cured. 

Notwithstanding  the  failures  of  the  past,  these 
victims  can  be  restored.  They  can  be  cured,  provided 
the  process  of  cure  is  a  rational  one,  one  which  will 
effectively  correct  the  physical  disorders  present  without 
creating  a  mania  to  be  left  in  its  stead.  When  these 
patients  are  really  cured,  physically  and  mentally,  when 
they  are  given  a  fair  chance,  a  large  per  cent,  of  them 
remain  well. 

It  is  well  to  consider  somewhat  in  detail  the  condi- 
tions which  favor,  and  which  render  unfavorable,  the 
prognosis.  Age  and  the  length  of  time  the  addiction  has 
existed  are  both  very  important  factors. 

The  age  of  the  patient  becomes  important  because  of 
the  difference  in  the  sensitiveness  of  a  nervous  system  in 
aged  persons  and  in  young  persons.  Then,  again,  the 
difference  in  ambition  of  the  two  ages  is  marked. 
Persons  in  early  life  seem  to  think  they  have  a  fund 
of  energy  and  reserve  resources  that  cannot  be  ex- 
hausted; therefore,  they  will  undertake  to  do  much 
more  than  their  strength  will  really  sustain  them  in. 
They  are  not  willing  to  take  the  affairs  of  life  moderately 
or  to  travel  at  a  moderate  rate.  They  often  seek  to  do 


Prognosis  More  Favorable  in  Aged.  281 

two  days'  work  in  one  and  thus  the  temptation  to  stimu- 
late to  enable  them  to  lengthen  out  their  working  hours 
is  very  great. 

Persons  who  have  no  fixed  convictions  as  to  the  use 
of  stimulants  are  very  prone  to  resort  to  them  to  sustain 
them  during  every  emergency.  Therefore,  those  who 
are  young  and  have  inadvertently  or  otherwise  become 
addicted  to  an  opiate  and  have  been  taken  off  it  feel 
as  if  they  have  lost  a  good  deal  of  time  during  their  ad- 
diction, and  must  now  make  up  that  loss.  If  this  idea  is 
not  overcome  by  caution  they  are  prone  to  take  stimu- 
lants of  some  kind  to  sustain  them  and  a  stimulant  of  any 
kind  is  simply  the  first  step  toward  confirmed  drug  ad- 
diction. 

On  the  other  hand,  older  persons  have  become  more 
settled  in  life  and  are  willing  to  take  life  at  a  slower 
pace.  Then,  too,  the  nervous  system  has  undergone  the 
changes  incident  to  age  and  their  reflexes  are  nothing 
like  so  active.  They  do  not  feel  so  acutely  or  so  intensely 
and  are  not  so  prone  to  seek  relief  from  every  slight 
ailment.  Therefore,  the  prognosis  in  aged  persons  is 
more  favorable  than  in  younger  ones. 

Another  factor,  a  very  important  one,  is  the  length 
of  time  the  drug  addiction  has  continued.  The  use  of 
opiates  during  the  first  year  or  two  years  of  addiction 
brings  some  pleasurable  sensations  to  the  drug  user.  It 
stimulates  and  brings  on  a  condition  of  ease  and  comfort 
which,  to  some  people,  is  very  delightful.  Then,  again, 
up  to  this  time  they  have  not  learned  to  dread  the  effects 
of  the  drug ;  they  cannot  see  that  it  has  done  them  much 
harm ;  they  have  not  felt  the  sting  of  the  abject  slavery 
due  to  its  use. 

Therefore,  so  long  as  the  drug  gives  them  a  pleasur- 
able sensation,  and  until  they  have  thoroughly  learned 


282  Narcotic  Drug  Diseases  and  Allied  Ailments. 

the  lesson  and  felt  the  sting  of  the  slavery,  they  are  more 
prone  to  experiment  with  it,  to  try  a  single  dose  for 
some  temporary  ailment,  than  they  would  be  had  the 
lesson  been  more  deeply  impressed  upon  them  by  pro- 
longed slavery  and  suffering. 

In  the  experience  of  the  author,  persons  who  are 
taken  off  the  drug  during  the  first  year,  or  even  during 
the  first  two  years,  of  their  addiction  are  more  prone  to 
return  to  it  than  those  who  have  been  enslaved  by  it  for 
a  longer  time.  This  rule  has  a  few  exceptions,  and  those 
exceptions  obtained  in  the  cases  of  those  who  are  forced 
into  the  addiction  by  some  serious  ailment,  and  who  have 
day  by  day  rebelled  against  it  and  have  not  in  any  way 
allowed  the  use  of  the  drug  to  obscure  their  judgment 
in  the  matter,  or  to  lead  them  to  use  it  as  a  dissipation  to 
any  extent  whatever.  Such  patients  as  these  are  curable 
at  any  stage,  and  if  given  a  proper  chance  for  freedom 
they  have  no  tendency  to  relapse.  As  a  rule,  until  one 
enslaved  by  morphine  has  had  an  experience  such  as  to 
make  him  abhor  the  drug  he  is  more  liable  to  resume  its 
use  than  he  would  be  after  that  experience  had  been  fully 
acquired.  Time  and  prolonged  suffering  are  often  neces- 
sary to  sufficiently  impress  this  lesson. 

Persons  of  50  or  more  years  of  age,  and  who  have 
taken  an  opiate  fifteen  to  twenty  years  continuously, 
have  less  tendency  to  relapse  than  younger  persons,  or 
than  those  who  have  used  the  drug  for  a  shorter  period. 
The  author  knows  a  number  of  such  persons  who  have 
remained  free  from  the  drug  notwithstanding  the  fact 
that  they  continued  to  suffer  from  a  chronic  ailment, 
such  as  asthma,  etc.,  after  the  cure  of  the  addiction. 

The  majority  of  relapses  which  have  occurred  in  the 
author's  work  have  been  due  to  the  use  of  alcohol  in 
some  form.  The  author  has  taken  great  pains  to  in- 


Use  of  Alcohol  Leads  to  Relapse.  283 

struct  his  patients  as  to  the  dangers  attending  the  use 
of  alcoholic  drinks,  and  many  of  them  have  lived  for 
years  according  to  those  ideas,  but  some  have  not.  It  is 
a  very  difficult  thing  to  bring  a  man  to  acknowledge, 
even  to  himself,  that  he  has  so  impaired  his  self-control 
as  to  be  unable  to  take  a  single  drink  of  some  alcoholic 
liquor  without  going  to  excess. 

After  they  have  remained  off  the  drug  for  some 
months,  or  even  a  year  or  so,  they  feel  that  they  have 
fully  regained  their  self-control,  and  that  they  can  do 
with  impunity  the  things  which  they  did  before  they 
became  addicted  to  a  narcotic ;  in  this  they  are  mistaken. 
The  narcotic  makes  an  impression  on  their  central 
nervous  system  and  upon  their  mind  and  powers  of  self- 
control  that  will  be  a  part  of  them  as  long  as  they  have 
a  memory. 

Alcohol  in  any  form  may  bring  about  a  state  of  well- 
being  and  comfort  for  a  short  time,  but  the  effects  of 
alcohol  are  very  transient.  As  soon  as  the  primary 
effect  begins  to  wane,  a  period  of  depression  occurs. 
This  depression  brings  acutely  to  the  memory  of  the 
individual  the  old  feeling :  the  old  unpleasant,  unnerved 
condition  which  he  so  much  dreaded  when  he  sought 
to  fight  off  taking  his  drug. 

The  depression  from  alcohol  is  intolerable  to  one  who 
has  been  a  victim  of  a  narcotic  drug,  and,  instead  of  bear- 
ing this  with  fortitude,  he  will  seek  another  drink  of  the 
alcoholic  mixture.  This  in  turn  brings  about  a  state  of 
well-being,  only  to  subside  in  a  very  short  time  to  the 
same  unpleasant  nervous  condition. 

In  this  manner  the  demand  for  the  alcoholic  bever- 
age is  very  rapidly  produced,  and  before  the  patient 
realizes  it  he  is  taking  from  three  to  a  dozen  drinks  of 
some  alcoholic  mixture  per  day.  This  continues  for  a 


284  Narcotic  Drug  Diseases  and  Allied  Ailments. 

few  weeks,  the  quantity  being  increased  until  the  nervous 
system  is  so  impaired  by  it  and  the  digestion  so  dis- 
ordered that  a  stronger  narcotic  must  be  taken  to  quiet 
the  nervous  system.  This  stronger  narcotic  soon  leads 
back  into  drug  slavery.  The  only  course  that  is  at  all 
safe  for  one  who  has  been  taken  off  of  a  narcotic  drug 
is  to  give  up,  for  good  and  for  all  time,  the  use  of 
alcohol  as  well  as  all  other  forms  of  narcotics. 

Even  coffee  does  harm.  It  would  not  be  so  hurtful 
if  it  were  only  the  stimulating  effect  that  is  produced 
by  it,  but  the  coffee  bean  contains  a  considerable  quan- 
tity of  tannic  acid  and  this  is  powerfully  astringent. 

The  effect  of  tannic  acid  on  the  digestive  organs  is  so 
damaging,  it  so  retards  the  activity  of  the  secreting  and 
excreting  organs,  that  the  system  soon  becomes  toxic 
under  its  influence.  This  astringent  effect  tends  to  pro- 
duce constipation.  Whatever  constipates  throws  the 
entire  system  out  of  order  and  brings  on  a  toxic  condi- 
tion, and  this  is  a  very  dangerous  condition  for  one  who 
has  been  a  drug  slave. 

One  who  would  remain  free  from  drug  slavery  must 
keep  his  vital  functions  in  a  good  working  state,  and  he 
cannot  do  this  if  he  takes  an  astringent,  such  as  coffee, 
into  his  system  or  uses  alcoholic  beverages  of  any  form. 

Tobacco  is  also  hurtful,  especially  cigarette  smoking, 
but  this  is  so  universal  and  seems  to  have  such  a  hold 
on  the  American  people  that  the  author  despairs  of  any 
reform  along  that  line.  To  be  at  all  secure  from  relapse, 
drug  habitues  who  have  been  freed  from  their  addiction 
must  cultivate  habits  of  regularity  and  live  free  from 
excesses  of  all  kinds. 


CHAPTER  XIV. 

ERRORS  IN  METHODS. 


SOME  REASONS  FOR  THE  PAST  FAILURES  IN  TREAT- 
MENT OF  MORPHINISM. 

IT  is  hardly  necessary  to  make  an  extensive  appeal 
to  medical  literature  to  show  that  failure  has  been  the 
almost  universal  result  of  attempts  at  treatment  of  the 
morphine  or  other  narcotic  drug  addiction  (disease). 
Observation  and  experience  have  doubtless  convinced 
most  physicians  that  such  is  the  fact.  So  far  as  can  be 
judged  from  the  expressions  of  physicians  with  whom 
the  writer  has  discussed  this  subject,  and  from  its  litera- 
ture, little  hope  has  been  held  out  to  this  class  of  sufferers 
by  our  profession. 

Anders,  in  his  recent  work  on  "Practice,"  says: 
"The  treatment  is  manifestly  difficult"  .  .  .  and  "the 
likelihood  of  a  cure  is  extremely  remote."  Da  Costa 
says,  "There  is  no  remedy  for  the  opium  habit."  This  is 
in  accord  with  the  prognosis  given  by  other  writers. 

These  opinions  are  based  upon  the  accumulated  ex- 
periences of  the  past,  and  it  must  be  admitted  that  .the 
extreme  rarity  of  curing  a  patient  of  this  class  by  any 
of  the  methods  known  to  medical  literature  fully  justifies 
these  conclusions. 

The  treatment  of  morphinism  has  usually  been  under- 
taken in  one  of  three  ways,  known,  respectively,  as  the 
"sudden-withdrawal,"  the  "rapid-reduction,"  and  the 
"gradual-reduction"  methods.  The  names  by  which 
these  methods  of  treatment  are  known  indicate  the 
general  course  of  procedure  in  each.  The  gradual-re- 

(285) 


286  Narcotic  Drug  Diseases  and  Allied  Ailments. 

duction  method  has  been  the  one  most  often  resorted  to, 
and  until  recently  it  has  had  the  almost  universal  in- 
dorsement of  American  authors.  Let  us  consider  the 
reasons  for  failure  when  this  method  has  been  resorted 
to. 

In  this  method,  without  preparatory  treatment,  the 
supply  of  the  drug  is  diminished  day  by  day,  until  in  the 
course  of  four  to  twelve  weeks  the  last  of  the  drug  is  left 
off.  This  entire  course  of  treatment  is  attended  by 
general  malaise,  wakefulness,  restlessness,  nervousness, 
and  at  times  persistent  nausea  and  diarrhea  with  ex- 
treme prostration,  and,  usually,  by  the  time  the  last  of 
the  drug  is  left  off,  the  poor  victim  is  so  exhausted  that 
he  is  unable  to  maintain  himself  without  resort  to 
other  stimulants. 

Of  this  condition  Erlenmeyer  says:  "The  patient 
after  withdrawal  is  left  in  such  a  condition  of  physical 
weakness  and  mental  dilapidation  as  to  be  the  victim  of 
intolerable  suffering  and  unfit  for  enjoyment  or  applica- 
tion to  work.  He  cannot  sleep,  he  has  no  appetite,  often 
vomits,  and  feels  too  much  used  up  to  rise  from  bed. 
This  condition  continues  for  a  long  time  and  grows 
worse  from  week  to  week.  Various  attempts  at  cure 
prove  useless.  A  return  to  morphine  is  the  only  remedy/' 

To  palliate  this  condition  strychnine  and  alcoholic 
drinks  were  usually  freely  administered,  with  chloral 
and  other  hypnotics  to  induce  sleep. 

The  drug  in  the  system  was  considered  "The 
Malady" ;  in  fact,  the  only  element  in  the  case  requiring 
attention.  To  withdraw  or  discontinue  that  was  the 
aim  of  all  therapeutic  endeavor.  When  the  patient  had 
been  off  his  drug  for  a  few  days,  or  a  few  weeks  at 
most,  the  cure  was  considered  complete. 

In  order  to  see  more  clearly  wherein  past  methods 
have  been  at  fault,  let  us  consider  the  pathology  of  this 


Fallacies  of  Gradual  Reduction.  287 

condition.  Structurally,  we  will  say  that  the  pathology 
is  nil,  as  no  structural  changes  are  discernible  either  in 
the  brain  or  other  tissues  of  the  body. 

The  pathological  changes  are  entirely  of  a  functional 
nature,  but  these  are  marked  and  well  defined,  and  are 
most  noticeable  in  the  digestive  tract.  The  tongue  is 
coated,  the  breath  is  foul,  constipation  is  habitual,  appe- 
tite is  poor,  digestion  is  much  impaired,  and  the  powers 
of  assimilation  are  so  diminished  that  the  entire  muscular 
and  nervous  system  is  in  a  state  of  semistarvation. 
Oxidation  of  the  blood  is  imperfectly  accomplished,  ex- 
cretion and  secretion  are  impaired,  and  the  entire  system 
is  surcharged  with  the  products  of  denutrition. 

Let  us  consider  the  effects  of  the  first  dose  of  mor- 
phine introduced  into  the  system.  These  are  a  state  of 
quietude  or  torpor ;  drowsiness,  soon  succeeded  by  sleep, 
with  diminished  or  completely  arrested  peristaltic  action ; 
constipation,  with  reduced  activity  of  all  the  secreting 
and  excreting  glands.  In  the  course  of  eight  to  twelve 
hours  the  hypnotic  effects,  as  well  as  most  of  the  other 
effects,  have  subsided,  and  the  functional  activity  of  the 
system  has  become  normal,  and,  possibly,  secretion  and 
excretion  are  carried  on  at  a  slightly  accelerated  rate, 
but  it  requires  several  days  for  this  increased  activity  of 
the  excreting  organs  to  free  the  system  from  the  prod- 
ucts of  waste  that  should  have  been  eliminated  during 
the  time  these  functions  were  retarded  by  the  benumbing 
influence  of  this  drug. 

Now,  if  before  that  is  accomplished  another  dose  of 
the  drug  is  taken,  the  eliminators  are  again  interfered 
with  in  their  work,  and  if  this  is  repeated  from  day  to 
day  the  system  soon  becomes  surcharged  with  the 
products  of  tissue  disintegration  and  their  fermentative 
products.  These  products  play  a  much  more  important 


288  Narcotic  Drug  Diseases  and  Allied  Ailments. 

role  in  causing  the  difficult  complications  met  upon  the 
withdrawal  of  morphine,  known  as  abstinence  symp- 
toms, than  does  the  drug  itself. 

It  cannot  be  shown  that  the  drug  in  the  system,  or 
its  oxidized  product, — oxydimorphine, — atom  for  atom, 
is  more  poisonous  to  the  patient  than  are  the  products 
of  tissue  disintegration,  and,  since  these  are  present  in 
many  times  greater  quantities  than  the  drug  or  its 
product,  they  should  be  looked  upon  as  the  chief  patho- 
logical factor  so  far  as  the  physical  disorder  is  concerned. 
In  the  treatment  of  these  addictions  the  drug  in  the 
system  is  not  so  much  to  be  contended  with  as  the  prod- 
ucts of  waste  which  it  imprisons  therein. 

Pari  passu  with  this  physical  poisoning  go  the  mental 
changes.  The  will-power  is  greatly  impaired,  mental 
activity  and  independence  of  action  and  thought  are 
diminished,  and  in  their  stead  a  state  of  indecision  and 
dependence,  with  a  morbid  dread  of  pain,  are  established. 

The  drug  user  becomes  thoroughly  confirmed  in  the 
belief  that  his  well-being  and  even  his  life  depend  on  his 
receiving  his  supply  of  drug  regularly.  This  completely 
robs  him  of  independence  and  self-assertiveness.  The 
mind  is  blunted,  inactive,  servile,  dependent;  unable  to 
receive  with  acuteness  new  impressions  or  to  readily 
recall  those  formerly  received.  He  feels  that  he  is  a 
helpless  victim  in  the  clutches  of  a  monster  with  whom 
he  is  totally  unable  to  cope;  his  mental  surrender  and 
enslavement  are  complete. 

These  mental  impressions  are  deep  and  lasting,  and, 
even  if  the  physical  disorder  is  fully  overcome,  this 
mental  state  alone,  if  left  uncorrected,  will  perpetuate 
dependence  upon  drugs. 

While  morphinism  has  been  classed  as  a  mania,  and 
the  importance  of  the  mental  side  has  been  insisted  upon 


Damaging  Mental  Impressions.  289 

by  some  medical  writers,  in  the  treatment  usually  advised 
the  mental  element  has  not  received  that  practical  rec- 
ognition that  its  importance  demands  or  that  could 
reasonably  be  expected  to  correct  such  a  disorder.  In 
fact,  the  course  of  therapeutic  management  has  usually 
been  such  as  to  perpetuate  the  mental  bias,  the  mania,  if 
one  existed  rather  than  to  overcome  it. 

Let  us  examine  the  leading  features  of  a  case  treated 
by  the  gradual-reduction  method  and  see  if  there  is  any- 
thing in  that  course  that  could  be  expected  to  cure  a 
mania.  The  patient  is  taking,  say,  20  grains  of  morphine 
a  day  at  two  doses,  hypodermically.  The  physician  plans 
to  reduce  the  dose  by  i  grain  a  day  for  the  first  ten  days 
and  then  by  a  less  quantity  until  zero  is  reached  in  thirty 
or  forty  days. 

After  the  first  three  or  four  reductions  the  dose  does 
not  entirely  relieve  the  patient,  nor  does  that  measure 
of  relief  last  until  the  time  for  the  next  dose.  Several 
hours  before  the  time  for  each  succeeding  dose  the 
patient  begins  to  be  more  uncomfortable  and  to  look  for- 
ward to  the  next  dose. 

Time  drags  heavily  and  as  the  hour  for  his  dose 
draws  nearer  his  suffering  increases  and  his  anxiety  for 
the  drug  is  greater.  Thus,  his  mind  dwells  on  the  drug 
and  its  effects  from  hour  to  hour  and  his  dependence 
upon  it  is  more  and  more  deeply  impressed  upon  him. 
This  is  continued  day  after  day,  and  as  his  doses  grow 
smaller  the  relief  is  less  complete  and  the  hours  of 
suffering  longer. 

While  the  reduction  was  being  made,  each  injection 
gave  a  measure  of  relief,  and  the  patient  was  thus  taught 
to  expect  and  depend  upon  them  for  relief,  and,  notwith- 
standing the  fact  that  the  zero  point  in  the  reduction 
may  have  been  reached,  the  physician  stil]  finds  it  neces- 


19 


290  Narcotic  Drug  Diseases  and  Allied  Ailments. 

sary  to  give  the  injections  at  the  accustomed  time,  and, 
while  these  may  now  contain  no  opiate,  about  the  same 
measure  of  relief  is  obtained  as  when  they  did  contain 
the  opiate,  simply  from  the  mental  impression,  sugges- 
tion of  relief,  which  the  patient  had  been  taught  to  expect 
from  them. 

When  the  patient  had  been  taken  off  his  drug  by  this 
process  and  kept  off  by  supervision  and  restraint  for  a 
few  weeks,  and  his  physical  condition  sufficiently  im- 
proved, he  was  discharged  as  cured,  notwithstanding  the 
fact  that  the  profound  mental  impressions  made  on  him 
during  this  protracted  and  trying  ordeal  were  still  vivid 
and  uneffaced. 

Now,  it  is  contended  that,  no  matter  how  excellent  a 
patient's  physical  condition  may  become,  following  such 
an  ordeal  he  is  not  cured  of  the  addiction  in  any  reason- 
able sense  of  the  word,  but  that  he  is  still  as  truly  a 
morphinomaniac  as  he  was  the  day  the  treatment  was 
begun  and  even  more  so. 

Such  a  patient  will  as  certainly  return  to  the  use  of 
the  drug  as  he  is  given  his  liberty,  not  because  all  mor- 
phine patients  relapse,  for  they  do  not,  but  because  he 
was  not  really  cured. 

This  long-drawn-out  course  of  treatment,  the  re- 
peated anticipation  and  realization  of  relief  from  the 
drug,  coupled  with  entire  failure  to  get  relief  from  other 
sources,  has  so  intensified  and  perpetuated  his  depend- 
ence upon  the  drug  that  the  mental  disorder,  the  mental 
habit,  the  mania,  is  as  strong  as  ever,  yes,  much  stronger 
and  will  control  his  conduct. 

In  order  to  be  successful  in  the  treatment  of  these 
addictions,  the  therapeutic  management  must  be  such  as 
to  overcome  the  mental  habit,  the  mania,  as  well  as  cure 
the  physical  disease,  but,  instead  of  the  gradual-reduc- 


Durability  of  Mental  Impressions.  291 


tion  method  doing  that,  it  is  the  most  effective  manner  of 
perpetuating  this  mental  disorder  that  the  ingenuity  of 
man  could  devise. 

Mental  impressions,  ideas,  control  the  conduct  of 
men;  in  fact,  the  habit  of  life,  the  character,  is  simply 
the  sum  or  product  of  the  mental  impressions  received 
by  the  individual. 

It  is  a  well-known  fact  that  some  of  the  greatest 
geniuses  the  world  has  ever  known  were  dominated  by 
one  idea;  also  that  many  insane  persons  are  perfectly 
sane  upon  all  subjects  but  one,  but  upon  that  they  are 
intensely  insane.  Without  any  discernible  change  in 
either  the  function  or  structure  of  the  brain,  this  one 
idea  has  become  so  implanted  in  the  mind  that  it  is  dwelt 
upon  to  the  exclusion  of  all  others. 

This  is  true  of  the  morphinomaniac.  Upon  all  other 
subjects  he  may  be  perfectly  sane,  but  upon  this  he  has  a 
mania.  In  this  case  the  mania  is  the  product  of  sug- 
gestion. The  frequently  repeated  thought — autosug- 
gestion— of  relief,  of  a  state  of  well-being  from  the  use 
of  the  drug,  has  so  firmly  implanted  this  idea  in  his  mind 
that  he  inevitably  follows  it. 

It  has  been  fully  demonstrated  that  mental  impres- 
sions can  be  so  fixed  in  the  mind,  so  indelibly  stamped 
upon  the  mental  machinery  by  suggestion  alone,  that 
such  impressions  will  dominate  the  life  of  the  individual. 

To  illustrate  the  power  and  permanency  of  mental 
impressions,  an  incident  in  the  life  of  a  prominent 
minister  which  is  well  vouched  for  is  here  related.  After 
partaking  of  a  sumptuous  repast  with  one  of  his  parish- 
ioners, this  preacher  set  out  on  horseback  for  his  next 
appointment. 

After  riding  several  miles  through  the  woods  he 
came  to  a  small  strip  of  prairie.  Upon  entering  this  he 


292  Narcotic  Drug  Diseases  and  Allied  Ailments. 

noticed  the  carcass  of  a  horse  a  short  distance  from  the 
road  in  a  high  state  of  decomposition.  The  odor  from 
this  was  so  disagreeable  that  before  he  could  pass  it  he 
was  intensely  nauseated  and  vomited  freely.  He  says 
he  thought  nothing  of  this,  as  a  disagreeable  odor  would 
often  nauseate  him,  and  that  he  had  not  thought  of  this 
experience  for  many  months,  when,  more  than  a  year 
afterward,  he  had  occasion  to  pass  that  way  again. 
Upon  arriving  at  the  little  prairie  and  seeing  the  bones 
of  this  animal,  notwithstanding  no  odor  emanated  from 
them,  the  impression  made  on  his  mind  on  his  former 
trip  recurred  to  him  with  such  force  that  he  at  once 
became  sick  at  his  stomach  and  vomited. 

If  a  single  impression  can  have  such  a  deep  and 
abiding  effect  on  a  normal  man,  how  much  more  lasting 
may  we  expect  these  impressions  to  be  on  one  whose 
mind  is  already  warped  and  subdued  to  a  state  of 
dependence  upon  a  drug,  if  that  dependence  is  accen- 
tuated by  the  repeated  expectation  and  realization  of 
relief  from  its  use?  Is  it  not  reasonable,  in  fact  inevi- 
table, that  these  impressions,  made  day  after  day 
throughout  a  protracted  course  of  treatment,  should  be- 
come an  integral  part  of  the  man's  mental  state ;  that  they 
should  dominate  his  conduct  as  completely  as  a  mania  of 
any  other  type  would  do? 

Is  it  not  a  matter  of  common  experience  that  mental 
states  do  dominate  men  in  all  the  walks  of  life?  Then 
why  should  we  not  look  for  it  and  acknowledge  its 
potency  in  the  morphinomaniac  ?  When  we  do  this  and 
intelligently  plan  our  course  of  treatment  so  as  to  effec- 
tually correct  this  mental  disorder  at  the  same  time  that 
we  cure  the  patient  of  his  physical  disease,  we  may 
reasonably  expect  success  to  attend  our  efforts,  but  not 
until  then. 


Desire  for  Cure.  293 

It  is  essential  to  recognize  the  fact  that  we  have  to 
deal  with  a  condition  presenting  a  dual  disease,  a  mental 
and  physical  disorder,  either  of  which  would  be  sufficient 
to  control  the  conduct  of  the  patient  and  cause  a  return 
to  the  use  of  the  drug,  even  if  the  other  were  entirely 
overcome. 

Instead  of  pursuing  a  course  of  therapeutic  treat- 
ment that  will  intensify  the  disordered  mental  state,  the 
therapeutic  measures  should  be  such  that  they  may  be 
used  to  correct  the  mania,  overcome  the  patient's  de- 
pendence upon  his  drug,  and  re-establish  confidence  in 
himself.  A  patient  of  this  class  should  not  be  considered 
cured  until  his  mental,  as  well  as  his  physical,  equilibrium 
has  been  restored. 

Much  difference  of  opinion  exists  in  the  profession 
as  to  the  curability  of  drug  habitues.  In  discussing  this 
subject  a  few  years  ago  before  a  medical  association  one 
physician  took  the  position  that  "None  of  these  cases 
were  ever  cured  by  treatment,  that  he  had  never  seen  a 
drug  habitue  who  wanted  to  be  cured  and  would  not 
believe  one  who  said  he  had  been  cured." 

Another  physician,  a  prominent  neurologist,  said 
that  "He  agreed  fully  with  the  former  speaker,  that  all 
persons  who  fall  a  victim  to  narcotic  drugs  were  pri- 
marily neurotic  by  nature,  that  they  were  all  unstable  in 
character  and  temperament." 

A  large  per  cent,  of  the  members  of  the  profession 
hold  opinions  in  accord  with  the  two  just  quoted,  and 
these  opinions  have  filtered  down  to  the  laity  until  public 
opinion  has  been  molded  by  them. 

Such  opinions  as  these  arise  mainly  from  the  fact 
that  physicians  and  the  public  generally  have  most  often 
come  in  contact  with  only  the  lowest  type  of  drug 
habitues,  those  who  are  "down  and  out,"  who  from 


294  Narcotic  Drug  Diseases  and  Allied  Ailments. 

poverty  or  other  adverse  conditions  have  been  forced  to 
resort  to  all  manner  of  questionable  means  to  secure  a 
drug  supply,  and  who  because  of  these  hard  conditions 
have  lost  all  hope  and  hold  on  life. 

It  is  by  impressions  made  by  drug  habitues  of  this 
class  that  professional  and  public  opinion  has  been 
molded,  but  these  "down  and  outs"  in  no  wise  represent 
the  great  army  of  drug  slaves  who  have  innocently  or 
inadvertently  been  entrapped  into  slavery,  and  who  bear 
their  misfortune  in  silence  and  keep  themselves  out  of 
public  view. 

The  idea  that  only  neurotics  fall  a  victim  to  narcotic 
drugs  is  absurd.  Anyone,  be  he  ever  so  stoical,  will 
become  enslaved  by  a  narcotic  if  it  is  given  to  him  con- 
tinuously for  a  sufficient  time.  It  is  true  that  those  of  a 
neurotic  temperament  fall  into  drug  slavery  much  more 
readily  than  those  of  a  normal  type,  but  none  are  exempt, 
none  able  to  resist  its  prolonged  effects. 

Those  who  hold  to  the  view  that  drug  habitues  do 
not  want  to  be  cured  could  not  be  more  greatly  mistaken. 

A  large  majority  of  them  want  to  be  cured  and 
only  continue  to  live  in  their  abject  slavery  because  of 
the  hope  which  they  have  of  at  some  time  being  freed 
from  it.  In  many  cases  their  life  is  one  continuous 
prayer  for  freedom,  coupled  with  repeated  efforts  to  ob- 
tain it.  If  the  hope  of  being  freed  from  drug  slavery 
were  extinguished  the  victim  would  commit  suicide. 

The  reason,  in  fact  the  only  reason,  that  a  large  per 
cent,  of  these  cases  have  not  been  permanently  cured  is 
that  the  methods  by  which  their  cure  has  been  attempted 
are  grossly  unscientific  and  inefficient,  and  therefore 
could  not  be  expected  to  succeed.  The  profession  has 
taken  a  very  uncomprehensive  and  one-sided  view  of 
this  subject,  and  because  of  failure  to  cure  them  by 


'Curability  Fully  Established.  295 

inefficient  methods  has  come  to  look  upon  them  as 
wantonly  abandoned  to  their  habit  and  incurable. 

No  opinion  was  ever  more  incorrect  or  unjust. 
These  people  not  only  desire  to  be  cured,  but  morphinism 
is  the  most  readily  curable  of  all  the  chronic  ailments, 
and  when  the  cure  is  really  effected  it  is  as  permanent 
as  the  cure  of  any  other  disease. 

The  curability  of  drug  addiction  is  no  longer  a  matter 
of  doubt:  the  evidence  of  their  almost  universal  cura- 
bility that  is  now  available  is  sufficient  to  convince  any- 
one. They  are  curable  by  the  methods  which  the  author 
has  brought  to  the  attention  of  the  profession,  and  he 
has  no  hesitation  in  saying  that  those  who  hold  contrary 
views  had  as  well  now  begin  to  revise  their  opinions  on 
this  subject.  If  the  more  than  three  thousand  drug 
habitues  which  the  author  has  treated  with  a  failure  to 
cure  in  less  than  i  per  cent,  could  be  marshaled  before 
the  profession  and  their  condition  seen  and  their  testi- 
mony taken,  the  cure  of  narcotic  addiction  would  not  be 
longer  questioned.  While  these  disenslaved  ones  cannot 
be  bodily  brought  to  the  view  of  the  profession  at  a 
glance  or  in  mass,  they  are  multiplying  and  are  being 
seen  and  their  conduct  watched  by  such  a  number  of 
medical  men  that  the  available  testimony  will  soon  be 
so  overwhelming  as  to  convince  the  most  skeptical. 

That  the  cures  may  be  more  permanent,  it  is  well 
to  consider  further  the  management  of  the  mental  ele- 
ment in  these  cases. 

Our  methods  should  be  varied  according  to  the  vary- 
ing phases  of  the  mental  disorder  found  in  the  case. 

There  is  a  vast  difference  in  drug  habitues :  some  are 
merely  morphinists,  while  others  are  morphinomaniacs. 
The  morphinist  is  cured  when  his  physical  disease  is 
overcome,  provided  he  is  not  made  a  morphinomaniac  by 


296  Narcotic  Drug  Diseases  and  Allied  Ailments. 

the  treatment  to  which  he  is  subjected  in  doing  this. 
A  considerable  per  cent,  of  drug  users  are  morphino- 
maniacs  and  require  both  physical  and  mental  treatment. 

The  management  of  the  mental  aspect  of  any  case 
depends  upon  the  character  of  the  mania  which  exists. 
In  most  cases  the  leading  features  of  the  mania  will  be 
found  to  be  a  firm  conviction  that  the  drug  is  essential 
to  life  and  comfort:  that  intolerable  suffering  and 
probably  death  would  occur  if  they  were  deprived  of  it ; 
that  no  other  drug  will  take  its  place  or  relieve  any  of 
their  ailments ;  that  the  drug  is  their  only  friend  and  only 
source  of  reliance. 

While  they  have  no  faith  in  drugs  other  than  this 
one,  they  will  be  found  to  have  less  faith  in  physicians 
in  all  matters  touching  their  addiction;  in  fact,  they 
usually  possess  a  morbid  suspicion  or  distrust  of  physi- 
cians in  all  things  connected  with  their  addiction. 

When  a  man  of  this  class  presents  himself  for  treat- 
ment the  first  step  is  to  engage  him  in  conversation. 
Ascertain  the  manner  and  cause  of  formation  of  the  ad- 
diction, the  number  of  efforts  the  patient  has  made  to 
leave  off  the  use  of  the  drug  and  with  what  success,  the 
number  and  character  of  treatments  he  has  taken,  the 
duration  and  severity  of  the  suffering  endured  while 
undergoing  these  treatments,  as  well  as  following  them, 
and  the  final  results.  In  other  words,  make  a  full  and 
accurate  inventory  of  the  patient's  mental  state  and  the 
different  experiences  that  have  contributed  to  its  for- 
mation. 

When  you  have  finished  talking  with  him  you  will 
wonder  how  it  is  that  he  has  confidence  enough  in  you 
to  apply  for  treatment,  but  you  need  not  flatter  yourself 
too  much ;  if  you  will  make  careful  inquiry  on  that  point 
you  will  find  that  he  has  just  barely  enough  faith  in  you 


Mental  State  of  Habitues.  297 

to  bring  him  across  the  threshold  of  your  institution,  but 
no  more. 

You  may  assure  him  that  you  can  cure  him  of  his 
addiction  in  a  short  time  and  with  little  suffering,  and, 
while  this  is  what  he  wishes  to  hear  you  say,  he  cannot 
and  does  not  accept  it  as  really  true.  You  may  bring  him 
into  the  company  of  other  cured  patients  and  let  them 
give  him  the  most  positive  assurance  that  they  have 
taken  treatment,  and  that  you  have  done  all  and  more 
than  you  promised  to  do  for  them,  yet  his  past  experience, 
especially  if  he  has  taken  several  treatments  without 
success,  so  contradicts  all  of  this  that  he  cannot  believe 
any  of  these  statements,  and  yet  his  anxiety  to  be  free 
from  drug  slavery  and  the  latent  hope  of  securing  such 
freedom  that  still  lingers  in  his  bosom  lead  him  to  take 
the  treatment. 

Having  obtained  a  full  knowledge  of  his  mental 
state,  you  are  ready  to  enter  upon  the  treatment.  The 
first  step  is  to  make  a  searching  physical  examination. 
In  treating  other  diseases,  this  is  made  to  ascertain  the 
patient's  physical  condition,  and,  while  this  is  one  of  your 
objects  in  making  this  examination,  it  is  not  the  only  one 
or  even  the  chief  one. 

The  one  absolute  prerequisite  to  success  is  to  gain  the 
confidence,  the  perfect,  unquestioning  trust,  of  your 
patient,  which  you  have  found  to  be  so  completely 
wanting. 

This  examination  should  be  made  with  such  care  and 
thoroughness  and  with  such  diagnostic  instruments  as 
to  fully  impress  upon  the  patient  that  you  are  a  master 
in  your  profession,  and  that  he  is  now  in  the  hands  of 
one  who  is  able  to  contend  successfully  with  all  his 
physical  ailments,  as  well  as  his  drug  addiction.  Your 
manner  should  be  one  of  quiet,  unassuming  self-pos- 


298  Narcotic  Drug  Diseases  and  Allied  Ailments. 

session,  positive,  confident,  but  by  no  means  self- 
assertive. 

During  or  following  this  examination  explain  to  the 
patient  the  pathology  of  his  condition:  the  cause  and 
manner  of  development  of  the  various  painful  symptoms 
which  he  has  experienced  in  his  efforts  to  leave  off  the 
drug  or  during  his  former  treatments. 

Take  him  completely  into  your  confidence,  as  much 
as  if  he  were  a  physician  in  consultation.  Do  not  treat 
lightly  any  of  the  painful  symptoms  which  he  has  ex- 
perienced during  or  following  his  former  efforts  to  leave 
off  the  drug.  Make  a  careful  explanation  of  the  cause 
of  each  and  explain  to  him  the  methods  by  which  you 
expect  to  avoid  them  in  the  treatment  you  are  preparing 
to  give  him,  and  assure  him  positively  that  you  will  be 
able  to  do  so. 

Tell  him  that  you  do  not  expect  to  wait  for  these 
symptoms  to  develop,  but  that  you  will  remove  their 
cause  beforehand  and  thus  prevent  their  development. 
Tell  him  that  when  his  system  is  fully  cleansed  of  effete 
material  and  his  addiction  cured,  as  you  are  preparing  to 
cure  it,  his  system  will  respond  to  other  remedies,  and 
that  it  will  not  be  necessary  to  resort  to  morphine  to 
relieve  any  ailment  he  may  have. 

While  your  patient  will  not  fully  accept  any  of  your 
assurances  at  this  time,  it  is  well  to  give  them  before- 
hand, as  suggestions  are  often  first  doubted,  then  con- 
sidered, and  finally  accepted  and  acted  upon. 

Remember  that  the  mania  in  these  cases  is  not  due 
to  structural  lesion  of  the  brain,  but  is  the  product  of 
suggestion  and  is  therefore  amenable  to  treatment  by 
suggestion,  provided  the  suggestive  treatment  for  the 
mania  is  given  in  connection  with  efficient  therapeutic 
measures  by  which  the  physical  disorder  is  overcome. 


Corrective  Mental  Impressions.  299 

Suggestion  is  one  of  the  most  potent  forces  with 
which  man  is  thrown  in  contact.  It  influences  everyone, 
and  at  all  times.  Every  man,  no  matter  what  his  char- 
acter may  be,  is  constantly  influenced  by  suggestion  and 
is  influencing  someone  else  by  suggestion.  It  is  an 
omnipresent  and  powerful  force  in  the  life  of  every 
human  being. 

Be  careful  never  to  deceive  your  patient  in  any  par- 
ticular and  to  make  him  only  such  promises  as  you  will 
be  able  to  fully  redeem,  and  see  that  he  realizes  as  a 
personal  experience  every  assurance  you  give  him.  A 
thorough  knowledge  of  the  subject,  absolute  truthful- 
ness, and  the  exercise  of  a  proper  discretion  are 
essential. 

After  having  in  this  manner  laid  the  groundwork  for 
the  corrective  mental  impressions  which  you  wish  to 
make  on  him,  begin  the  eliminating  course,  purgatives, 
baths,  etc.  Explain  to  him  the  effect  you  expect  from 
this  eliminating  course.  Tell  him  that  he  has  an 
enormous  quantity  of  effete  material  stored  in  his  system 
which  this  course  of  treatment  will  remove,  and  that  as 
this  is  being  removed  the  principal  cause  of  his  former 
trouble  will  go  with  it.  Tell  him  that  he  will  have  the 
most  copious  discharges  from  his  bowels  that  he  has  ever 
had,  and  that  the  removal  from  his  system  of  this  offen- 
sive excreta  will  very  largely  overcome  the  desire  and 
necessity  for  his  drug  and  will  also  prevent  the  develop- 
ment of  the  distressing  diarrhea,  colic,  vomiting,  heart 
complications,  extreme  nervousness,  and  many  other  of 
the  painful  symptoms  which  he  has  so  fully  described  to 
you. 

See  that  the  purgative  acts  as  it  should  and  then  you 
will  be  in  a  position  to  remind  him  that  you  told  him 
beforehand  you  would  give  him  a  purgative  that  would 


300  Narcotic  Drug  Diseases  and  Allied  Ailments. 

act  freely  and  pleasantly,  that  the  discharges  would  be 
very  copious,  etc.,  all  of  which  he  is  now  realizing  to  be 
true. 

Note  carefully  every  development  in  the  case  that 
supports  the  assurances  and  promises  you  made  him, 
and  thus  make  one  step  toward  insinuating  yourself  into 
his  confidence ;  make  use  of  this  opportunity  to  give  such 
other  assurances  as  you  wish  to  impress  upon  him. 

Note  the  fact  that  it  is  now  several  hours  past  the 
time  for  his  accustomed  dose,  that  he  is  not  feeling  the 
need  of  his  drug,  and  that  he  is  not  anything  like  so 
nervous  as  usual  when  going  beyond  the  time  for  his 
dose.  Tell  him  that  when  he  does  begin  to  feel  the  need 
of  his  drug  you  will  give  him  another  remedy  which  will 
bring  about  complete  relief;  that  you  will  continue  to 
administer  this  remedy  two  to  three  days  and  then  dis- 
continue all  medicines,  and  that  he  will  then  have  no 
desire  for  his  drug  and  be  free  and  independent  of  it. 

When  elimination  has  been  satisfactorily  effected  and 
the  patient  begins  to  feel  the  need  of  his  drug,  begin 
scopolamine.  Give  this  as  indicated,  to  keep  him  from 
suffering,  but  do  not  overwhelm  consciousness,  as  you 
will  need  to  make  use  of  the  semiconscious  state  produced 
by  scopolamine  to  more  firmly  implant  the  suggestions 
you  have  heretofore  merely  intimated  to  him. 

Scopolamine,  if  discreetly  administered,  produces  a 
semiconscious  or  subconscious  state  similar  to  that 
known  to  psychologists  as  the  "psychic  state,"  in  which 
the  reasoning  faculties  are  inactive  and  that  part  of  the 
mind  known  as  the  subconscious  mind  is  in  control. 

In  this  state  the  patient  does  not  reason,  but  accepts 
as  true  and  acts  upon  suggestions  given  him.  This 
state  should  be  made  use  of  to  fully  disabuse  his  mind  of 
any  delusions,  convictions,  or  ideas  that  he  still  has  that 


Confidence  of  Patient  Essential.  301 

which  would  militate  against  his  remaining  free  from 
the  addiction  and  to  implant  such  contrary  or  opposing 
ideas  as  are  needed  to  make  him  a  self-reliant,  hopeful, 
independent  man. 

As  the  patient  comes  out  from  under  the  influence  of 
scopolamine  he  will  realize  still  further  that  the  assur- 
ances you  gave  him  are  true.  He  will  find  that  he  is  not 
nervous  or  suffering,  as  he  expected  to  be.  While  you 
told  him  he  would  not  be  so,  he  could  not  accept  your 
assurances,  but  now  these  are  realized  as  true  by  his 
own  senses,  which  he  cannot  question,  and  your  words 
begin  to  have  much  greater  weight  with  him. 

He  finds  that  his  own  experiences  are  hour  by  hour 
confirming  every  assurance  you  gave  him,  and  he  is  thus 
forced  to  have  confidence  in  you.  For  the  next  few  days 
you  should  assiduously  cultivate  this  growing  confidence 
of  your  patient  until  you  bring  him  to  the  point  that  he 
no  longer  questions  anything  you  say,  but  will  accept  as 
absolute  truth  any  assurance  you  give  him.  You  will 
have  thus  step  by  step,  but  effectively,  developed  him 
into  a  "psychic"  so  far  as  you  and  your  words  are 
concerned. 

By  this  time  every  assurance  you  have  given  him 
will  probably  have  been  verified,  except  the  assurance 
that  if  he  should  become  affected  with  any  slight  or  even 
grave  disorder  other  remedies  will  give  him  relief. 

Watch  your  opportunity  and,  when  complaint  is 
made  of  any  ailment,  select  the  remedy  that  would  give 
anyone  else  relief  and  administer  it  to  him ;  at  the  same 
time  assure  him  that  it  will  relieve  him,  and,  contrary  to 
the  general  rule,  tell  him  just  what  you  are  giving.  In 
this  way  demonstrate  to  him  the  truthfulness  of  your 
words  as  to  this  matter  also  and  fully  satisfy  him  that 
other  remedies  will  now  have  the  same  effect  on  him  that 


302  Narcotic  Drug  Diseases  and  Allied  Ailments. 

they  do  on  others,  and  that  it  will  not  be  necessary  for 
him  to  again  resort  to  the  use  of  morphine  for  the  relief 
of  any  ailment  he  may  have. 

Teach  him  that  morphine  is  not  his  best  or  only 
friend,  but  that  it  is  really  his  worst  enemy  and  in  every 
way  possible  prejudice  him  against  its  use.  Fully  con- 
vince him  of  his  independence  of  the  drug  and  send  him 
from  you  a  free,  happy,  self-reliant,  independent  man, 
instead  of  an  abject,  dependent  slave,  as  when  he  came 
to  you.  Instead  of  being  suspicious  of  all  physicians  and 
skeptical  of  the  potency  of  all  drugs,  except  his  one,  have 
him  implicitly  trusting  in  you  and  testifying  to  the  effi- 
ciency of  the  remedies  in  ordinary  use  to  relieve  any 
ailment  he  may  have. 

You  should  project  your  personality  into  his  life  so 
fully  and  forcibly  that  you  can  and  do  control  his  mental 
state  and  send  him  from  you  with  your  mind  and  person- 
ality engrafted  upon  and  dominating  him.  If  this  is  well 
and  skillfully  done,  these  impressions  will  abide  with 
him  and  control  his  conduct  as  completely  as  did  the 
mania  for  his  drug  which  these  have  supplanted. 

The  treatment  of  this  disease  is  more  than  the  prac- 
tice of  medicine;  it  is  not  only  the  scientific  use  of  all 
proper  therapeutic  measures,  but  it  involves  also  the 
bringing  to  your  aid  all  the  God-given  qualities  of  mind 
and  heart  by  which  the  life,  conduct,  and  opinions  of 
your  patient  can  be  affected,  to  the  end  that  he  may  be 
sent  out  into  the  world  an  independent,  self-reliant  man 
mentally  and  physically  healed. 


CHAPTER  XV. 

A  PLEA  FOR  A  MORE  JUST  JUDGMENT  OF 
NARCOTIC  DRUG  USERS. 

WHEN  the  author  began  the  preparation  of  this 
chapter  he  intended  its  title  to  be  "A  Plea  for  a  More 
Charitable  Judgment  of  Narcotic  Drug  Users,"  but  on 
getting  into  the  subject  more  fully  he  saw  that  it  is  not 
charity  that  he  should  ask,  but  simple  justice.  There- 
fore, he  enters  a  plea  for  justice  and  not  for  charity. 

He  hopes  to  show  that  thousands  of  the  most 
wretched  and  helpless  of  all  human  beings  are  being  con- 
stantly and  openly  stigmatized  as  degenerates,  willful 
perverts,  inveterate  liars,  and  fiends,  and  are  having 
numerous  other  epithets  of  reproach  and  condemnation 
heaped  upon  them  for  continuing  a  course  of  conduct  to 
which  they  are  impelled  by  forces  that  it  is  totally  beyond 
their  power  to  resist. 

Whether  an  opium  addiction  is  formed  from  neces- 
sity or  as  a  dissipation,  justifiably  or  unjustifiably,  the 
condition  finally  becomes  the  same,  and  when  the  condi- 
tion of  confirmed  addiction  is  reached  it  is  as  truly  a  dis- 
ease as  is  typhoid  fever,  and  the  normal  supply  of  the 
drug  used  is  a  necessity  for  the  comfort  and  well-being 
of  the  victim. 

Let  us  consider  for  a  few  minutes  the  condition  into 
which  an  opium  user  is  thrown  by  being  deprived  of  his 
drug.  Wilson,  vol.  v,  Pepper's  "System  of  Medicine," 
says : — 

"Opium  habitues,  differing  as  they  do  among  themselves  as 
long  as  the  drug  is  freely  taken,  all  alike  develop  characteristic 
symptoms  upon  its  speedy  or  gradual  withdrawal.  .  .  .  The 

(303) 


304  Narcotic  Drug  Diseases  and  Allied  Ailments. 

nervous  system,  whether  it  has  been  accustomed  for  months  only 
or  for  years  to  the  influence  of  opiates,  is,  upon  their  withdrawal, 
forthwith  thrown  into  derangements  of  the  most  serious  and 
widespread  kind. 

"In  the  course  of  a  few  hours  after  the  last  dose,  the  steadying 
influence  of  the  drug  disappears.  General  malaise  is  associated 
with  progressive  restlessness;  the  ability  to  perform  the  ordinary 
duties  of  life  gives  way  to  profound  indifference;  precordial  dis- 
tress, accompanied  by  cough,  is  followed  by  insomnia,  halluci- 
nations, and  sometimes  mania.  The  habitual  pallor  of  the  face  is 
replaced  by  a  deep  flush  or  cyanosis. 

"The  heart's  action  becomes  excited  or  irregular,  then  feeble ; 
the  pulse,  at  first  tense,  becomes  slow,  thready,  and  irregular. 
Attacks  of  yawning  and  sneezing  are  followed  by  convulsive 
twitching  of  the  hands.  Speech  becomes  hesitating,  drawling, 
and  stuttering. 

"These  phenomena  are  associated  with  a  sense  of  perfect 
prostration,  which  obliges  the  patient  to  take  his  bed.  Pains  in 
the  back  and  limbs  followed  by  neuralgia  occur.  Complete 
anorexia  with  easily  provoked  or  even  causeless  vomiting  and 
persistent  nausea  with  diarrhea  difficult  to  control  add  to  the 
gravity  of  the  condition. 

"During  the  early  days  of  the  abstinence,  the  evidences  of 
cardiac  failure  are  marked.  Enfeeblement  of  the  first  sound, 
irregularity  of  the  heart's  action,  and  intermissions  are  common. 
Restlessness  is  continuous  and  very  often  intense,  and  patients  are 
with  difficulty  kept  in  bed.  If  left  to  themselves,  they  move 
frantically  about  the  room,  moaning  and  bewailing  their  condition 
and  begging  the  attendant  for  that  which  alone  is  capable  of 
relieving  their  distress. 

"This  condition  gradually  subsides,  giving  way  to  one  of 
profound  exhaustion.  .  .  .  The  appearance  of  the  patient  is 
now  most  pitiable.  The  countenance  is  blanched  and  pinched, 
the  body  drenched  with  sweat,  the  heart  action  feeble,  the  pulse 


Abstinence  Symptoms.  305 

thready  and  irregular.  .  .  .  Failure  of  the  circulation  may,  not- 
withstanding every  effort  to  control  it,  reach  such  a  degree  as 
to  jeopardize  the  patient's  life." 

Erlenmeyer  says: — 

"The  patient  after  withdrawal  is  left  in  such  a  condition  of 
physical  weakness  and  mental  dilapidation  as  to  be  the  victim  of 
intolerable  suffering.  .  .  .  He  cannot  sleep,  has  no  appetite, 
often  vomits,  and  feels  too  much  used  up  to  rise  from  bed.  This 
condition  grows  worse  from  week  to  week.  Various  attempts 
to  cure  prove  useless.  Morphin  is  the  only  remedy." 

Butler's  "Therapeutics,"  p.  452,  says : — 

"The  treatment  of  so  dire  a  malady,  for  such  the  chronic 
use  of  morphin  must  be  regarded,  demands  the  utmost  fore- 
thought, patience,  and  tact.  The  method  of  sudden,  absolute  with- 
drawal of  the  drug  is  admitted  by  the  wisest  observers  to  be 
fraught  with  dangers  commensurate  with  that  of  the  indulgence 
to  be  overcome.  Collapse,  insanity,  and  other  serious  results 
have  attended  so  drastic  a  measure.  The  gravity  of  the  situation 
should  from  the  first  be  fully  realized,  since  it  is  too  often  simply 
a  case  of  life  or  death,  the  patient  being  not  infrequently  seized 
with  the  desire  of  self-destruction  in  the  extremes  of  mental 
anguish  occasioned  by  the  ordeal  imposed  by  unwonted  ab- 
stinence." 

Other  writers  of  undisputed  authority  enumerate  in- 
tolerable suffering,  violent  delirium,  transient  or  perma- 
nent dementia,  suicide,  and  death  as  occurring  to  drug 
users  through  being  deprived  of  their  drug  supply. 

Notwithstanding  these  clear  and  distinct  teachings 
by  men  of  unquestioned  authority,  the  great  majority  of 
professional  men  regard  the  users  of  narcotic  drugs  as 
being  willfully  abandoned  to  a  loathsome  habit  which 
they  could  discontinue  if  they  would. 


20 


306  Narcotic  Drug  Diseases  and  Allied  Ailments. 

As  a  result  of  their  holding  such  views  the  public 
has  been  taught  to  regard  these  victims  as  perverts  who 
are  devoid  of  moral  courage  and  right  purposes  in  life 
and  who  take  their  drug  simply  to  dream  away  the  time 
and  who  are  unworthy  of  any  treatment  other  than 
social  ostracism. 

The  fact  that  such  opinions  are  generally  held  among 
the  people  is  a  matter  of  common  knowledge,  and  when 
one  falls  a  victim  to  a  drug,  however  strongly  he  may 
have  condemned  others  for  what  he  considered  a  volun- 
tary, loathsome  habit,  he  soon  finds  there  is  another 
side  to  the  question. 

Comparatively  few  persons  form  the  opium  habit 
voluntarily  or  as  a  dissipation.  Usually  it  is  formed 
inadvertently  or  because  of  the  use  of  the  drug  for  the 
relief  of  pain. 

There  are  very  few  drug  users  who  have  not  made 
many  and  often  very  desperate  efforts  to  extricate  them- 
selves from  the  thraldom  of  the  drug,  or  who  have  not, 
by  some  circumstance  or  other,  been  deprived  of  their 
drug  supply.  These  efforts  at  abandonment  or  periods 
of  deprivation  have  brought  upon  them  the  sufferings 
incident  to  the  disuse  of  the  drug,  and  these  have  proved 
to  be  so  excruciating  and  intolerable  as  thoroughly  to 
convince  them  that  the  voluntary  abandonment  of  the 
drug  is  entirely  out  of  their  power :  that  what  they  once 
blamed  others  for  not  doing,  they  are  themselves  unable 
to  do. 

While  such  experience  may  have  worked  a  radical 
change  in  their  own  opinions,  they  are  well  aware  that 
public  opinion — the  irresistible  moral  force — has  not 
undergone  any  such  change.  They  are  acutely,  or  pos- 
sibly morbidly,  sensitive  to  that  fact,  but  they  are  not 
changed  in  their  purposes  in  life,  in  their  desire  to  have 


Public  Opinion,  Errors  in.  307 

and  retain  the  respect  and  confidence  of  their  friends  and 
the  public  in  general. 

They  still  love  life,  and  their  good  name  is  as  dear  to 
them  as  ever.  They  feel  confident  of  their  own  integrity 
and  good  purposes,  but  they  know  that  the  drug  has 
become  a  necessity  to  them.  They  also  know  that  if  their 
use  of  the  drug  should  become  known  the  blighting  sting 
of  public  opinion  would  lacerate  their  very  souls ;  there- 
fore, in  order  to  shield  themselves  from  criticism  and 
censure,  springing  from  what  they  now  know  to  be  mis- 
guided public  opinion,  they  procure  their  drug  and  use 
it  in  secret. 

Thus  they  start  out  leading  a  double  life,  a  life  of 
deception,  with  a  skeleton  in  the  closet  that  must  be  kept 
constantly  concealed  from  public  gaze,  but  the  motives 
which  prompt  them  to  that  course  are  not  dishonorable. 

Self-preservation  is  said  to  be  the  first  law  of  nature. 
A  man  is  justified  under  the  law  in  taking  the  life  of  his 
fellow-man  when  necessary  to  preserve  his  own,  and  in 
the  protection  of  his  good  name,  which  to  a  right-think- 
ing man  is  as  dear  as  his  life,  very  great  liberty  of  action 
is  allowed. 

The  acts  that  are  held  to  be  a  perversion  of  character, 
manifested  by  many  of  these  persons,  are  not  due  to  the 
physiological  effects  of  opium,  or  to  any  pathological 
condition  induced  by  it. 

The  use  of  this  drug  does  not,  of  itself,  beget  de- 
generacy. This  springs  largely,  if  not  altogether,  from 
another  source.  This  is  clearly  shown  from  the  fact  that 
drug  users  who  are  independent  of  such  influences  main- 
tain their  integrity,  sustain  their  good  name,  and  retain 
the  respect  and  confidence  of  their  associates. 

To  illustrate  this  point  the  history  of  three  cases 
is  here  given : — 


308  Narcotic  Drug  Diseases  and  Allied  Ailments. 

CASE  I. — The  patient  is  a  druggist  who  has  used  morphine 
1 8  years,  running  up  in  quantity  during  the  time  to  1.3  grams 
(20  grains)  per  day.  He  has  during  all  that  time  continued  to 
attend  to  his  business,  has  been  successful  as  a  business  man,  has 
built  up  and  held  a  large  trade,  and  has  himself  done  much  of  the 
prescription  work  and  other  delicate  work  connected  with  the 
business.  His  family  and  his  physician  knew  of  his  addiction, 
but  never  at  any  time  reproached  him  for  it  or  tried  to  control 
him  with  reference  to  it. 

The  public  had  no  occasion  to  know  of  it,  or  to  be  concerned 
about  it,  and  therefore  asked  no  questions.  Being  a  druggist  and 
independent  financially,  his  drug  supply  was  always  at  hand,  and 
was  taken  at  regular  intervals,  and  in  uniform  quantities.  In  this 
way  he  kept  himself  in  a  fairly  normal  condition,  and  neither  the 
public  nor  the  people  with  whom  he  did  business  suspected  his 
use  of  the  drug. 

A  uniform  supply  of  the  drug  was  as  necessary  to  keep  him 
in  a  normal  and  comfortable  condition  as  it  would  have  been  for 
any  other  drug  user,  but,  being  in  a  position  to  have  entire  control 
of  the  drug  supply,  and  as  his  family  made  no  objection  to  his 
course,  and  did  not  at  any  time  attempt  to  stand  between  him 
and  his  drug  supply,  he  was  not  forced  to  use  deception  or  other 
questionable  means  to  obtain  the  necessary  thing.  Being  thus 
favorably  situated,  he  was  able  to  retain  the  confidence  of  his 
family  and  friends,  and  of  the  public  at  large. 

CASE  II. — A  case  similar  to  the  foregoing  was  that  of  a 
physician  who  became  addicted  to  the  use  of  morphine  during 
a  protracted  attack  of  inflammatory  rheumatism,  and,  after  about 
six  months'  use  of  the  drug  for  the  relief  of  that  ailment,  the 
rheumatic  symptoms  subsided  and  an  effort  was  made  to  dis- 
continue the  drug,  but  without  success. 

After  a  little  delay,  another  effort  was  made  with  the  same 
result.  The  suffering  resulting  from  these  efforts,  with  the 
necessary  resort  to  the  drug  for  relief  in  each  instance,  fully  con- 


Opium,  per  se,  Does  Not  Cause  Degeneracy.  309 

vinced  the  doctor  and  his  family  that  it  was  out  of  his  power  to 
discontinue  it,  and  they  all  accepted  the  situation  and  looked  upon 
his  addiction  as  a  misfortune  for  which  he  was  in  no  way  to 
blame,  and  from  that  time  on,  for  more  than  twenty  years,  he 
continued  the  use  of  the  drug  with  the  full  knowledge  and  consent 
of  his  family,  but  without  his  patrons  or  the  public  knowing  any- 
thing whatever  of  it. 

He  kept  an  ample  supply  of  his  drug  always  at  hand  and  used 
it  in  uniform  quantities  and  at  regular  intervals,  and  during  all 
these  years  he  kept  up  an  active  practice,  and  held  the  confidence 
of  his  patrons  and  of  the  business  public. 

He  was  always  an  unwilling  slave,  and  no  element  of  dissipa- 
tion was  allowed  to  enter  into  his  addiction.  He  bought  the  drug 
in  tablet  form,  so  as  to  be  exact  about  the  dose,  and  only  took  a 
sufficient  quantity  to  keep  him  comfortable.  In  this  way  he 
succeeded  in  holding  the  dose  down  to  0.39  gram  (6  grains)  or 
less  per  day.  On  days  when  he  had  little  to  do  he  used  not  more 
than  0.26  gram  (4  grains),  but  on  other  days,  when  there  were 
taxing  duties  to  meet  and  when  his  hours  of  work  had  to  be 
prolonged  into  the  night,  as  much  as  0.39  gram  (6  grains)  was 
required  to  sustain  him. 

From  his  appearance  or  conduct,  no  one  would  ever  suspect 
his  being  a  drug  user,  and  he  was,  when  he  came  for  treatment, 
in  an  active  practice  and  holding  a  number  of  official  positions  in 
the  profession.  He  was  a  man  of  intelligence  and  of  fine  family 
and  character  and  very  acutely  felt  his  slavery.  He  said  that  he 
realized  the  drug  was  injuring  him,  especially  his  memory ;  there- 
fore, he  wanted  to  be  released  from  its  thraldom. 

CASE  III. — Another  of  this  type  was  a  refined,  delicate 
woman  who  had  been  given  morphine  for  several  months  to  pre- 
vent an  abortion,  and  after  her  confinement  she  was  unable  to 
discontinue  it.  She  made  repeated  efforts,  with  the  assistance  of 
her  husband,  to  leave  off  the  drug,  but  her  condition  in  each 
instance  became  so  critical  that  her  husband  would  not  consent 


310  Narcotic  Drug  Diseases  and  Allied  Ailments. 

to  her  making  further  effort  in  that  direction,  and,  instead  of 
chiding  her  or  blaming  her  for  inability  to  leave  off  the  drug,  he 
bought  it  for  her  in  sufficient  quantities  and  told  her  to  use  it  as 
she  found  it  necessary. 

She  suffered  from  a  number  of  ailments,  which  led  to  an 
increase  of  the  dose  to  about  1.3  grams  (20  grains)  per  day,  but 
for  several  years  no  one  knew  of  the  use  of  the  drug  except  her 
husband  and  her  physician.  Later  her  father  and  brothers  were 
informed  of  it,  and,  as  they  had  heard  of  the  author's  work  in 
this  line,  they  urged  her  to  come  for  treatment. 

When  she  was  admitted  her  husband  and  brother  gave  a 
history  of  the  case,  her  husband  stating  that  he  recognized  it  as  a 
misfortune,  for  which  his  wife  was  in  no  wise  to  be  blamed,  and, 
since  he  realized  that  it  was  out  of  her  power  to  quit  it,  he  had 
kept  her  supplied  with  the  drug,  so  that  she  had  never  been 
forced  to  obtain  it  in  any  other  way  or  to  resort  to  deception  in 
regard  to  its  use.  He  said  that  she  had  always  been  perfectly 
open  and  frank  with  him  about  the  matter  and  that  the  use  of 
the  drug  had  not  in  the  least  rendered  her  unreliable  or  untrust- 
worthy. 

She  was  in  the  institution  about  six  weeks,  and  was  found  to 
be  entirely  truthful  and  trustworthy,  never  at  any  time  attempt- 
ing to  deceive,  or  indulging  in  extravagant  or  unfounded  state- 
ments. In  fact,  she  showed  the  same  high  sense  of  honor  and 
exercised  the  same  caution  in  statement  and  respect  for  her 
word  that  would  be  expected  of  a  woman  of  refinement  and 
culture  afflicted  with  any  other  disease,  notwithstanding  the  fact 
that  she  had  been  using  morphine  in  considerable  quantities  for 
more  than  five  years. 

These  are  fairly  representative  of  a  large  per  cent, 
of  drug  users  who  come  under  the  care  of  one  engaged 
in  the  treatment  of  such  patients.  It  is  true  that  drug 
users  of  this  class  are  almost  unknown  to  the  public  and 


Proper  Treatment  of  Habitues.  311 

are  very  little  known  to  physicians  in  general  practice, 
but  they  are  not  at  all  rare  among  those  who  apply  for 
admission  to  institutions  devoted  to  the  treatment  of 
such  patients. 

The  mere  use  of  opiates  does  not  make  perverts  or 
moral  degenerates  of  people  who  were  of  good  character 
before  the  use  of  the  drug  was  begun,  and  the  fact  that 
some  such  persons  do  retain  their  integrity  and  sustain 
their  character  and  standing  in  the  communities  in  which 
they  live,  notwithstanding  the  use  of  the  drug,  forces 
us  to  look  elsewhere  than  to  the  effect  of  the  drug  for  an 
explanation  of  the  traits  of  character  usually  seen  in 
drug  users.  Let  us,  therefore,  study  the  history  of  a 
few  other  cases. 

CASE  IV  is  of  a  different  type,  but  at  the  beginning  her 
character  and  standing  were  first  class.  She  was  a  member  of  a 
good  family  and  married  to  a  lawyer  of  prominence.  She  made 
an  ideal  wife,  loved  her  home,  and  devoted  herself  largely  to 
making  it  attractive  to  her  husband.  Something  over  a  year  after 
her  marriage  she  became  the  mother  of  a  fine  boy,  who  was  the 
delight  of  both  father  and  mother,  and  for  the  next  two  years 
their  home  was  an  ideal  one. 

About  this  time  another  conception  occurred.  All  went  well 
until  about  the  fourth  month,  when  she  was  threatened  with  a 
miscarriage.  The  family  physician  was  called,  and  it  became 
necessary  to  confine  her  to  bed  and  administer  morphine  for 
about  ten  days  to  prevent  an  abortion.  She  was  then  allowed  to 
get  up  and  a  few  days  later  the  symptoms  returned. 

She  was  again  put  to  bed  and  morphine  was  administered 
and  this  time  continued  for  three  weeks  without  the  intermission 
of  more  than  a  full  day.  Morphine  was  then  discontinued  and 
she  was  allowed  to  get  up,  but  in  a  few  days  the  uterus  became 
rebellious  again  and  it  was  necessary  to  resume  the  use  of  the 
opiate. 


312  Narcotic  Drug  Diseases  and  Allied  Ailments. 

By  continuing  the  opiate  from  that  time  on,  she  was  carried 
to  her  full  term  and  delivered  of  a  healthy  child.  She  had  both 
a  perineal  and  a  cervical  injury  at  the  confinement,  which  pro- 
tracted her  convalescence  and  caused  considerable  suffering,  and 
the  morphine  was  continued  until  the  baby  was  two  months  old. 
By  this  time  she  had  sufficiently  regained  her  strength  to  be  up 
and  about  the  house.  Her  physician  then  told  her  that  it  would 
not  be  necessary  to  use  the  opiate,  ordered  it  discontinued,  and 
dismissed  the  case. 

In  about  twenty-four  hours  her  suffering  became  so  acute 
that  he  was  again  called,  but  declined  to  give  an  opiate,  insisted 
that  her  suffering  was  mainly  imaginary,  and  told  her  husband 
that  as  soon  as  she  found  that  she  could  get  more  morphine  she 
would  become  quiet  and  quit  complaining. 

Her  husband  believed  this  and  told  her  that  he  would  not 
allow  her  to  have  more  of  the  drug  under  any  circumstances,  and, 
leaving  her  with  the  servants,  went  on  to  his  business. 

As  the  addiction  had  been  confirmed  by  more  than  six  months' 
use  of  the  drug,  her  sufferings  increased  until  they  became  un- 
bearable, and,  realizing  that  she  could  not  expect  relief  from 
either  husband  or  physician,  she  sent  a  servant  out  and  obtained 
a  bottle  of  laudanum.  A  full  dose  of  this  gave  her  a  fair  degree 
of  relief  and  when  her  husband  came  home  in  the  evening  she 
was  more  quiet  and  he  felt  that  the  doctor's  word  had  come  true 
and  that  they  had,  by  their  firmness,  broken  his  wife  from  the 
use  of  morphine.  But  he  was  mistaken. 

When  the  first  bottle  of  laudanum  was  exhausted,  more  was 
obtained.  This  was  used  as  sparingly  as  possible,  and  she  made 
numerous  efforts  to  leave  it  off  altogether.  Finding  herself 
unable  to  do  so,  she  continued  it,  and  by  discreet  management 
used  it  for  a  period  of  two  years  before  it  was  detected  by  her 
husband. 

When  he  did  become  aware  of  it,  he  reproached  her  for  it 
very  severely,  and  again  applied  to  his  physician  for  advice  in 


Effects  of  Harsh   Treatment.  313 

the  matter.  The  physician  assured  him  that  her  use  of  the  drug 
was  a  mere  dissipation,  a  habit  that  could  be  abandoned  at  will, 
and  advised  that  if  she  did  not  leave  it  off  voluntarily  she  be 
compelled  to  do  so. 

Her  husband  urged  her  to  leave  off  the  drug,  and  she  promised 
to  do  so,  and  did  try  faithfully,  but,  of  course,  she  could  not 
succeed.  Her  husband  criticised  her  severely  for  her  failure  to 
keep  her  promises  in  the  matter,  and  attributed  to  her  all  kinds 
of  evil  purposes. 

Finding  that  these  did  not  avail,  he  determined  to  cut  off  the 
drug  supply.  He  deprived  her  of  money,  and  notified  all  the 
druggists  in  his  town  not  to  sell  her  on  credit,  and  urged  them  not 
to  sell  her  opiates  at  all. 

This  made  it  necessary  for  her  to  resort  to  many  expedients 
to  procure  her  drug,  and  even  then  she  was  not  able  to  obtain  it 
regularly.  When  she  could  not  obtain  the  drug  by  other  means, 
she  would  sell  her  clothing  to  negroes  and  get  them  to  buy  the 
drug  for  her.  Another  plan  was  to  order  groceries  and  sell  them 
at  reduced  rates  to  get  money  to  buy  the  drug. 

At  times  she  was  unable  by  any  of  these  means  to  obtain  her 
drug  supply,  and  at  such  times  she  would  secure  whisky  and 
drink  that.  This,  of  course,  disgusted  her  husband,  and  his  posi- 
tion became  one  of  extreme  bitterness  toward  her.  The  wife 
realized  that  it  was  out  of  her  power  to  comply  with  her  husband's 
wishes  and  discontinue  the  use  of  the  drug.  The  intense  suffer- 
ing that  came  on  when  she  was  out  of  her  drug  became  an 
impelling  force,  which  compelled  her  to  do  almost  anything  to 
obtain  that  which  alone  was  capable  of  giving  her  relief. 

The  position  occupied  by  her  husband  and  her  physician  was 
so  extreme,  and  they  so  totally  misunderstood  the  necessities  of 
her  case,  that  there  could  be  no  common  ground  of  agreement 
between  them.  They  felt  that  she  was  pursuing  that  course  from 
preference,  as  a  deliberate  choice;  that  she  had  lost  all  respect 
for  herself  and  for  her  family  and  had  become  totally  depraved, 
and  they  treated  her  accordingly. 


314  Narcotic  Drug  Diseases  and  Allied  Ailments. 

She  was  conscious  of  her  faithful  efforts  to  comply  with  their 
demands,  but  was  also  painfully  conscious  of  the  fact  that  it  was 
out  of  her  power  to  break  the  fetters  that  held  her  a  slave  to  the 
drug.  Strive  as  she  would,  she  could  not  do  so. 

Much  as  she  desired  to  regain  the  confidence  and  love  of  her 
husband,  the  unbearable  suffering  experienced  and  the  extreme 
desperation  brought  on  by  failure  of  her  drug  supply  impelled 
her  as  an  irresistible  force  to  turn  a  deaf  ear  to  all  their  en- 
treaties, to  disregard  all  promises  made  to  them  as  to  leaving 
off  the  drug,  to  smother  all  motherly  and  wifely  instincts,  if  need 
be,  and  to  continue  to  resort  to  all  forms  of  deception  and  intrigue 
that  were  found  necessary  to  obtain  her  drug  supply.  It  had,  in 
her  experience,  become  the  one  supreme  necessity  of  life. 

CASE  V. — D.  G.,  a  young  man  aged  18  years,  was  given 
morphine  seven  months  during  an  attack  of  rheumatism.  At  the 
end  of  that  time  the  rheumatic  symptoms  had  disappeared,  and 
his  father,  who  was  a  physician  and  had  attended  him,  decided 
to  withdraw  the  morphine  by  gradual  reduction,  and  began  to 
do  so. 

Things  progressed  fairly  well  for  a  time,  but  after  the  dose 
had  been  cut  down  considerably  the  suffering  of  the  patient  was 
extreme.  The  father  had  mapped  out  a  plan  which  he  felt  he 
must  not  vary  from.  The  son  suffered  intensely  for  a  number  of 
days,  but  all  his  pleadings  for  something  more  to  relieve  him  were 
ignored.  His  father  told  him  he  would  rather  see  him  a  corpse 
than  have  him  continue  the  use  of  morphine,  and  insisted  that 
the  course  he  was  pursuing  was  the  only  one  that  promised  relief, 
and  that  he  must  stand  the  suffering. 

The  reduction  was  continued  until  the  last  of  the  drug  was 
withdrawn,  but  the  condition  of  the  patient  was  most  desperate. 
He  could  not  sleep,  had  no  appetite,  was  extremely  nervous,  had 
an  exhausting  diarrhea  which  nothing  seemed  to  benefit,  and  in 
many  other  ways  his  suffering  was  unbearable. 

In  this  extreme  condition  the  son,  by  the  aid  of  a  friend, 
secured  a  supply  of  morphine  tablets.  These  were  used  very 


Coercion  Does  Not  Cure.  315 

sparingly,  and  only  enough  to  overcome  the  most  acute  suffering, 
the  young  man  feeling  that  if  he  could  only  get  a  little  relief 
he  could  bear  the  balance  of  the  suffering  and  finally  get  off  the 
drug,  which  he  was  very  anxious  to  do. 

The  father  noticed  the  improved  condition  of  the  son,  and 
felt  that  he  was  succeeding  in  curing  him  of  the  addiction.  In  a 
few  months,  however,  the  son's  efforts  to  hold  the  quantity  down 
and  to  keep  his  use  of  it  concealed  were  unavailing,  and  the  father 
learned  of  it.  He  was  very  much  incensed  at  what  he  termed 
his  son's  willful  disobedience  and  deception. 

He  then  determined  to  punish  him  and  cure  him  at  the  same 
time,  so  he  took  the  drug  supply  away,  put  an  attendant  with 
him,  and  locked  him  in  his  room. 

Here  for  the  next  three  days  he  suffered  the  tortures  incident 
to  the  abrupt  withdrawal  of  the  drug  without  treatment,  and  by 
the  end  of  that  time  his  condition  was  so  critical  that  the  father 
became  alarmed  and  gave  morphine  for  relief.  This  was  con- 
tinued for  a  few  days,  and  then  another  effort  was  made  to  with- 
draw it,  but  the  symptoms  became  alarming  again  and  the  drug 
was  resorted  to.  The  next  year  was  spent  in  one  effort  after 
another  to  break  up  the  addiction,  the  father  often  resorting  to 
harsh  means  and  even  cruel  treatment  in  his  efforts  to  force  the 
disuse  of  the  drug. 

This  only  served  to  widen  the  breach  between  the  father  and 
son,  and  to  drive  the  son  to  more  desperate  means  to  obtain  the 
drug  supply.  He  would  steal  his  father's  books  or  instruments 
or  anything  else  that  he  could  take  from  the  house  without  being 
immediately  detected,  and  sell  them  to  obtain  the  drug.  If  he 
could  not  get  morphine,  he  would  get  whisky  or  any  other  drug 
or  drink  which  would  to  any  degree  fill  its  place.  His  father 
looked  upon  these  acts  as  positive  evidence  of  extreme  perversion, 
and  regarded  him  as  utterly  abandoned  and  hopeless. 

The  last  two  cases  are  representative  of  a  large  per 
cent,  of  the  drug  users  in  the  United  States.  They 


316  Narcotic  Drug  Diseases  and  Allied  Ailments. 

present  a  sharp  contrast  when  compared  with  the  first 
three  cases  reported  in  this  chapter.  Between  them 
there  are  all  grades  and  varieties,  and,  while  they  all 
use  the  drug  in  common,  they  differ  radically  in  other 
respects,  but  it  is  evident  that  the  traits  of  character 
manifested  by  many  of  them  are  not  due  to  the  effect  of 
opiates. 

In  studying  the  history  of  a  large  number  of  patients 
who  were  unquestionably  of  good  character  prior  to  the 
formation  of  the  addiction,  the  author  has  found  that 
the  perverse  traits  of  character  were  prominent  or  not 
just  in  proportion  as  the  other  influences  herein  men- 
tioned were  prominent  or  not. 

If  the  addiction  was  formed  by  one  who  was  entirely 
independent  and  could  secure  and  use  the  drug  without 
being  interfered  with  by  anyone,  he  retained  his  integ- 
rity, his  business  and  social  standing,  etc.,  to  a  fair 
degree,  but  when  the  habitue  was  dependent  on  someone 
else  for  his  drug  supply,  and  this  one  a  person  who  did 
not  understand  the  necessities  of  his  condition,  or  when 
his  family  or  friends,  or  those  to  whom  he  was  subject, 
undertook  to  break  the  "habit"  by  withholding  the  drug 
supply  or  the  means  of  obtaining  it,  or  when  adverse 
fortune  made  it  necessary  for  the  drug  user  to  resort 
to  deception  and  other  such  means  to  procure  the  drug, 
the  perverse  traits  of  character  were  very  prominent. 

These  perverse  traits  were  present  in  proportion  to 
the  length  of  time  and  the  degree  of  intrigue  and  decep- 
tion the  drug  user  had  been  forced  to  use. 

The  conclusion  is  inevitable :  that  in  the  fourth  case 
herein  reported  the  failure  of  the  husband  and  physician 
properly  to  understand  the  condition  of  the  patient  and 
to  provide  the  relief  the  condition  demanded  forced  her, 
in  the  first  place,  to  begin  a  life  of  deception,  and  their 


Integrity  Not  Necessarily  Impaired.  317 

harsh  criticism  and  unjust  treatment  caused  her  to  con- 
tinue to  pursue  a  course  which  they  could  only  look  upon 
as  one  of  extreme  dissipation. 

The  same  influences  were  responsible  for  the  conduct 
of  the  patient  in  Case  V.  The  mistaken  views  held  by 
the  father  led  to  the  son's  wretched  condition. 

No  greater  mistake  was  ever  made  by  well-meaning 
persons  than  to  attempt  to  deprive  of  his  drug  supply 
one  who  is  addicted  to  the  use  of  morphine.  Such  efforts 
only  serve  to  drive  the  drug  user  to  secret  and  often 
immoral  acts  to  procure  his  supply. 

The  only  proper  and  reasonable  course  is  to  recognize 
the  condition  as  a  misfortune — a  disease,  as  it  really  is, 
and  one  which  cannot  be  overcome  by  merely  depriving 
the  patient  of  his  drug.  It  should  also  be  borne  in  mind 
that  it  is  a  really  hazardous  proceeding  to  deprive  a  drug 
user  of  his  drug  supply,  since  dementia  or  death  may  be 
the  result. 

Another  case  will  illustrate  still  another  phase  of 
this  subject : — 

CASE  VI. — C.  H.  T.  belongs  to  a  different  class.  His  parents 
were  in  moderate  circumstances,  but  lived  in  a  crowded  city 
district,  where  the  son  formed  acquaintances  that  were  anything 
but  desirable.  At  1 6  he  began  to  drink  and  gamble,  declined  to 
continue  in  school,  and  set  out  to  make  his  own  living. 

His  ideals  were  low  and,  having  no  well-defined  purpose,  he 
obtained  employment  first  at  one  thing  and  then  another,  but 
painting  seemed  to  be  his  preference,  and  by  the  time  he  was  20 
he  had  developed  considerable  skill  as  a  house  and  sign  painter. 
This  enabled  him  to  earn  good  wages  and  furnished  him  means 
with  which  to  buy  liquors. 

He  would  work  faithfully  for  a  few  weeks,  but  as  soon  as  he 
accumulated  a  little  money  he  would  go  on  a  spree  and  not  stop 
until  his  last  cent  was  spent  and  his  credit  exhausted.  His  money 


318  Narcotic  Drug  Diseases  and  Allied  Ailments. 

being  gone,  the  saloons  would  no  longer  shelter  him,  and  he  was 
frequently  taken  in  charge  by  the  police  and  sobered  up  under 
their  care. 

At  other  times  he  would  apply  to  physicians  for  something 
to  quiet  his  nervousness  and  enable  him  to  sober  up.  This  some- 
thing too  often  proved  to  be  morphine  given  hypodermically. 
This  had,  to  him,  a  most  delightful  effect,  bringing  quietude  to 
his  shattered  nerves  and  rest  to  his  excited  brain.  He  soon 
learned  that  under  the  influence  of  opiates  the  demand  for  strong 
drink  was  much  less  urgent  and  that  he  could  control  himself 
more  fully  than  when  using  whisky  alone. 

Being  a  venturesome  creature,  he  learned  the  use  of  the 
hypodermic  syringe  and  this  led  to  the  daily  use  of  the  drug. 
Things  progressed  fairly  well  with  him  for  the  next  year,  as  he 
used  much  less  whisky,  but  as  he  became  more  and  more  de- 
pendent on  the  drug  his  capacity  as  well  as  his  inclination  for 
work  declined.  His  income  decreased  until  it  was  not  sufficient 
to  support  him  and  supply  the  drug  he  was  using. 

He  then  began  to  resort  to  various  expedients  to  procure  his 
drug.  He  borrowed  from  friends  until  his  repeated  failures  to 
repay  forced  them  to  refuse  further  loans. 

His  next  resort  was  to  besiege  the  offices  of  physicians  with 
some  feigned  complaint  and  beg  them  to  give  him  the  drug,  but 
physician  after  physician,  tiring  of  these  calls,  turned  him  away 
without  further  assistance.  Then  being  more  desperate,  he 
began  to  beg  on  the  streets,  and,  when  these  appeals  did  not  bring 
the  necessary  funds,  larceny  of  any  article  that  he  could  pawn 
for  a  small  amount  was  resorted  to. 

These  thefts  brought  him  into  prominence  in  the  police  courts 
and  the  accounts  of  his  peculations  in  the  papers  brought  his  case 
to  the  notice  of  thousands  of  people.  When  he  would  become 
known  to  the  people  of  one  town  as  a  chronic  beggar  and  they 
no  longer  responded  to  his  appeals,  he  would  make  his  way  to 
another  town,  and  there  under  new  surroundings  he  would,  for 


Defects  of  diameter  Magnified.  319 

a  time,  be  more  successful  in  obtaining  assistance  from  physicians 
and  from  the  public.  But  sooner  or  later  he  would  be  brought 
before  the  public  as  a  morphine  fiend  who  had  committed  some 
crime,  almost  always  petit  larceny.  Later  on  his  thefts  became 
more  frequent  and  of  greater  magnitude,  and  he  is  now  serving 
a  term  in  a  State  prison  for  grand  larceny. 

It  will  be  noticed  that  this  man  was  reared  under 
rather  unfavorable  surroundings,  that  he  began  to  dis- 
sipate early,  had  no  very  high  ideals  or  well-defined 
purposes,  and  that  morphine  was  added  to  the  use  of 
whisky  more  as  a  dissipation  than  otherwise. 

This  case  belongs  to  a  class  that  forms  probably  15 
per  cent,  of  all  drug  users,  certainly  not  more  than  that, 
but,  while  they  are  comparatively  few  in  number,  they 
have  made  a  reputation  for  the  entire  generation  of  drug 
users. 

They  are  the  ones  who  have  been  constantly  before 
the  public  gaze ;  they  are  the  ones  with  whom  physicians 
have  often  come  into  unfavorable  contact,  both  at  their 
offices  and  at  the  public  institutions,  and  both  the  public 
and  the  profession  have  come  to  look  upon  them  as 
fairly  representative  of  the  entire  multitude  of  drug 
users.  Their  crimes  and  other  acts  of  perversion  have 
been  so  repeatedly  brought  to  the  public  notice  through 
the  press  and  the  courts  that  the  public  has  been  taught 
to  look  upon  all  narcotic  drug  users  as  of  this  class,  when, 
in  fact,  this  is  very  far  from  the  truth. 

One  drug  user  of  this  class  will  often  be  brought  to 
the  notice  of  many  thousands  of  people  in  an  unfavorable 
light,  while  there  are  in  the  same  population  hundreds 
of  other  drug  users  who  conduct  themselves  discreetly 
and  never  expose  themselves  to  the  public  gaze.  Many 
of  these  doubtless  compare  favorably  in  character  and 


320  Narcotic  Drug  Diseases  and  Allied  Ailments. 

standing  with  the  first  three  cases  reported  in  this 
chapter;  yet,  the  state  of  public  opinion  is  such  that  if 
their  use  of  the  drug  were  known  they  would  be  classed 
with  the  perverts  and  stigmatized  as  ''morphine  fiends." 

As  a  result  of  attributing  the  perverse  traits  of  char- 
acter manifested  by  some  morphine  users  to  the  effects 
of  the  drug,  both  the  profession  and  the  public  have 
fallen  into  the  error  of  looking  upon  all  opium  users  as 
of  the  same  class,  and,  since  the  comparatively  small 
number  of  perverts  among  them  are  the  ones  who  have 
become  most  commonly  known,  they  have  made  the 
reputation  by  which  all  are  judged. 

Such  a  conclusion  is  erroneous,  and  the  opinion  based 
upon  it  is  manifestly  unjust.  Drug  users  differ  from 
each  other  as  greatly  as  do  other  people. 

Some  of  them  retain  their  moral  character,  their 
veracity,  and  even  their  reputation  without  blemish, 
while  others  become  moral  wrecks,  but  it  is  evident  that 
other  influences  besides  the  effects  of  the  drug  are  potent 
factors  in  bringing  about  that  wreckage. 

If  the  reader  will  recall  for  a  moment  the  condition 
into  which  a  drug  user  is  thrown  by  being  deprived  of 
his  drug,  as  described  at  the  beginning  of  this  chapter, 
he  will  doubtless  admit  that  it  is  unreasonable  to  expect 
any  human  being  to  enter  upon  such  an  undertaking 
voluntarily,  or  to  submit  to  being  forced  into  it,  if  it  is 
in  his  power  to  prevent  it. 

The  author  does  not  hesitate  to  say  that  an  opium 
user  has  a  moral  right  to  resort  to  any  course  of  conduct 
that  may  be  necessary  to  obtain  his  drug  supply. 

If  that  course  of  conduct  should  embrace  untruth- 
fulness,  deception,  and  fraud,  it  does  not  place  him  on 
the  same  moral  plane  with  persons  guilty  of  the  same 
acts  when  the  motive  which  prompts  them  is  gain, 
personal  advancement,  or  other  such  motive. 


Erroneous  Opinion  as  to  Degeneracy.  321 

In  resorting  to  such  acts  for  the  purpose  of  obtaining 
a  drug  supply,  if  it  cannot  be  otherwise  obtained,  the 
drug  user  does  only  what  any  other  human  being  would 
do  under  the  same  circumstances,  and  no  one  should  be 
condemned  for  doing  that  which  anyone  else  would  have 
done. 

Every  drug  user  firmly  believes  that  if  he  were  de- 
prived of  his  drug  supply  he  would  either  die  or  go 
crazy,  and  he  therefore  feels  justified  in  doing  anything 
that  may  be  necessary  to  protect  himself  from  such  an 
extremity. 

Most  morphine  users  deny  their  habit,  and  on  that 
account  they  are  charged  with  being  notorious  liars  and 
unreliable  in  all  matters. 

Here,  again,  they  are  judged  with  undue  harshness. 
They  deny  the  use  of  the  drug  in  self-defense,  to  try  to 
preserve  their  good  name  and  to  protect  themselves  from 
the  criticism  and  censure  of  their  friends,  and  from  the 
sting  of  misguided  public  opinion. 

Since  the  motive  which  prompts  an  act  fixes  its  moral 
quality,  they  should  not  be  so  strongly  condemned  for 
denying  that  which,  if  admitted,  would  ruin  their  busi- 
ness and  social  standing,  and  convict  them  in  the  eyes 
of  the  public  of  being  willful  perverts  or  moral  degen- 
erates, and  lead  to  their  being  known  and  spoken  of  by 
the  inhuman  epithet  "morphine  fiend."  If  self-preserva- 
tion is  not  the  first  law  of  nature,  it  is  one  of  the 
strongest,  and  it  is  a  just  and  proper  motive  for  human 
action. 

The  conduct  of  persons  such  as  is  described  in  Case 
VI  of  this  chapter  has  created  another  impression,  both 
among  the  profession  and  the  laity,  which  is  without 
foundation.  That  is,  that  drug  habitues  are  not  curable, 
that  they  have  no  desire  to  be  cured,  and  would  not 
remain  free  from  the  drug  if  they  were  cured. 

21 


322  Narcotic  Drug  Diseases  and  Allied  Ailments. 

This  is  totally  without  foundation  when  persons  such 
as  are  noted  in  Cases  I,  II,  and  III  above  are  concerned. 
Drug  users  of  this  class  long  to  be  free  from  the  drug 
and  never  give  up  hope  of,  in  some  way,  securing 
freedom  from  it.  All  that  is  necessary  to  effect  perma- 
nent cures  in  such  cases  is  to  give  them  a  chance.  When 
they  are  taken  off  the  drug  and  put  in  such  physical 
condition  that  they  can  live  in  a  fair  degree  of  comfort 
without  it,  there  is  no  tendency  whatever  to  return  to  its 
use.  Fully  90  per  cent,  of  such  persons,  when  once  really 
cured  of  the  addiction,  will  remain  permanently  free 
from  it.  They  will  suffer  any  kind  of  torture  before 
they  will  allow  an  opiate  given  to  them. 

This  would  be  true  of  persons  such  as  are  described 
in  Cases  IV  and  V  if  they  were  properly  handled  early 
in  their  addiction,  but,  after  they  have  been  subjected  to 
the  tortures  of  physical  suffering  and  the  mental  anguish 
which  they  must  experience  from  the  harsh  and  cruel 
treatment  meted  out  to  them  by  those  from  whom  they 
would  naturally  look  for  kindness,  sympathy,  and  love, 
they  often  pass  the  stage  at  which  they  could  reassert 
their  self-control,  even  if  brought  into  a  physical  condi- 
tion to  do  so. 

The  discouragement  incident  to  the  breaking  up  of 
family  ties,  the  consciousness  that  their  loved  ones  have 
lost  confidence  in  them,  affects  them  so  unfavorably,  so 
undermines  their  confidence  in  humanity,  so  completely 
robs  them  of  hope,  that  they  have  not  the  courage  to  face 
the  world  and  to  take  up  the  duties  of  a  normal  life. 
Such  persons  feel  that  they  have  nothing  to  live  for,  and, 
even  if  they  are  cured  and  put  in  perfectly  normal  physi- 
cal condition,  they  are  not  secure  from  relapse. 

The  failure  of  physicians  to  permanently  benefit 
patients  of  this  class  whom  they  have  usually  undertaken 


Large  Percentage  Remain  Free.  323 

to  treat  in  the  wards  of  general  hospitals,  furnishes  the 
grounds  for  the  opinion,  generally  held  among  physi- 
cians, that  permanent  cures  are  not  to  be  expected  in 
drug  addiction.  This  opinion  is  totally  without  founda- 
tion with  reference  to  fully  50  per  cent,  of  drug  habitues 
and  is  subject  to  material  modification  in  the  remainder. 


CHAPTER  XVI. 

CONGENITAL  MORPHINISM,  WITH 
REPORT  OF  CASES. 


CONCEALED   MORPHINISM   IN   PARTURIENT  WOMEN. 

CONGENITAL  morphinism  is  a  rather  rare  condition. 
Comparatively  few  opium-using  mothers  conceive  and 
fewer  still  of  the  children  born  of  such  mothers  live 
beyond  the  third  day  after  birth.  This  high  mortality 
among  the  infants  of  such  mothers  is  not  unavoidable, 
but,  managed  as  they  usually  are,  a  large  majority  of 
children  born  to  such  mothers  die  on  the  second  or  third 
day  after  birth. 

This  is  due  to  the  fact  that  the  child's  blood  and 
tissues  are  as  fully  saturated  with  the  narcotic  as  are 
those  of  its  mother;  in  fact,  so  far  as  the  physical  ele- 
ments of  the  addiction  are  concerned,  the  child  is  as 
much  an  habitue  as  is  its  mother.  Severance  of  the 
placental  circulation,  through  which  the  child  had  been 
receiving  the  narcotic,  shuts  off  that  supply,  and,  if  the 
drug  is  not  administered  to  the  child,  it  suffers  the  shock 
and  collapse  incident  to  the  abrupt  withdrawal  of  opiates 
from  an  habitue. 

Few  adults  are  able  to  stand  such  a  strain ;  therefore, 
a  newly  born  infant  could  not  be  expected  to  do  so. 
Some  infants  born  under  such  conditions,  however,  are 
managed  so  as  to  preserve  their  lives  and  a  few  of  them 
have  come  under  the  author's  care.  Note  the  following 
cases : — 

In  May,  1901,  W.  T.  B.  and  wife  came  for  treatment 
for  morphinism,  bringing  two  children  with  them.  One 
(324) 


Morphinism  in  Young  Children.  325 

a  boy  3  years,  the  other  a  girl  I  year,  of  age.  The  mother 
was  using  morphine  before  the  first  conception  and  when 
the  baby  was  born  it  was  fortunately  under  the  care  of  a 
physician  who  realized  the  danger  of  the  sudden  with- 
drawal of  an  opiate  from  such  an  infant,  and  he  gave 
paregoric  in  full  doses  for  the  first  three  days  and  then 
the  baby  was  put  to  the  breast  and  allowed  to  get  its 
drug  supply  in  that  way. 

When  this  child  was  a  year  old  an  effort  was  made 
to  wean  it,  but  it  was  very  fretful  and  suffered  so 
severely  that  the  mother  says  she  did  not  have  the  heart 
to  deny  it  the  breast  and  it  was  allowed  to  continue  to 
nurse.  Notwithstanding  this,  however,  and  notwith- 
standing the  fact  that  she  continued  to  use  the  opiate  and 
that  menstruation  was  absent,  she  conceived  again  and 
the  girl  was  born  two  years  after  the  boy. 

This  child  was  managed  in  the  same  way  as  the  first 
for  the  first  few  days  after  birth  and  then  both  children 
were  allowed  to  nurse.  They  both  received  their  nar- 
cotic through  the  milk  and  the  mother  had  not  succeeded 
in  weaning  either  of  them.  Therefore,  they  were 
brought  with  her  for  treatment. 

The  mother  and  children  were  prepared  for  the  with- 
drawal of  the  opiate  by  active  elimination,  the  opiate  was 
discontinued,  and  they  were  given  the  usual  treatment, 
the  children  taking  the  same  remedies  as  the  mother,  but 
in  relatively  smaller  doses.  The  children  stood  the  treat- 
ment as  well  as  the  mother  and  all  were  brought  out  in 
good  condition  in  a  short  time. 

Neither  of  the  children  were  allowed  to  nurse  after 
the  treatment.  The  mother  was  much  emaciated  from 
the  drain  of  nursing  the  two  children,  but  her  convales- 
cence was  rapid  after  the  children  had  been  weaned  and 
both  the  mother  and  the  two  children  have  remained  free 


326  Narcotic  Drug  Diseases  and  Allied  Ailments. 

from  their  addiction.  The  children  are  healthy  and 
vigorous  and  show  no  evidence  of  their  former  addic- 
tion. It  has  been  now  a  little  over  ten  years  since  these 
cases  were  treated. 

In  Nov.,  1909,  a  Texas  physician  wrote,  asking  ad- 
vice as  to  the  management  of  his  wife,  who,  he  said,  was 
addicted  to  the  use  of  morphine  and  was  about  seven 
months  pregnant.  Not  being  able  to  find  anything  in 
medical  literature  to  guide  him  in  the  management  of 
such  a  case,  he  wished  the  author  to  give  him  such  aid  as 
he  could.  Had  the  patient  been  near  the  author  she 
would  have  been  taken  off  of  the  drug  even  at  that  ad- 
vanced stage  of  pregnancy,  but  a  long  railroad  journey 
for  such  a  patient  made  another  course  more  expedient. 

The  author  wrote,  expressing  the  opinion  that  the 
patient  could  be  carried  through  her  confinement  without 
complication,  and  advised  that  the  use  of  the  opiate  be 
continued  without  any  effort  at  reduction.  Atten- 
tion was  also  called  to  the  importance  of  keeping  up 
active  elimination  both  by  bowels  and  kidneys  during  the 
remainder  of  gestation  and  suitable  remedies  were  sug- 
gested for  that  purpose  to  the  end  that  the  patient's 
system  be  kept  in  the  best  condition,  and  that  she  be  as 
nearly  free  from  toxic  matter  as  possible  at  time  of  her 
confinement,  the  only  complications  likely  to  occur  being 
of  toxic  origin. 

These  suggestions  were  faithfully  carried  out,  and 
Dec.  3Oth  she  was  delivered  of  a  healthy  child,  at  full 
term,  in  a  normal  labor. 

Six  hours  after  the  delivery,  the  child  began  to  show 
signs  of  restlessness  and  discomfort,  and  following  the 
plan  outlined  it  was  given  a  drop  of  laudanum  and  this 
was  repeated  in  half  an  hour.  This  did  not  give  relief, 
and  one  hour  later  2  drops  were  given  at  one  dose. 


Treatment  of  Addiction  in  Infancy.  327 

This  gave  relief  and  the  baby  was  quiet  for  several  hours, 
but  when  it  began  to  show  signs  of  discomfort  again,  3 
drops  of  laudanum  were  given  at  one  dose. 

This  proved  to  be  a  fairly  effective  dose,  and  a  dose 
of  this  size  was  given  every  six  hours  for  the  next  two 
days.  By  this  time  the  milk  flow  was  fairly  well  estab- 
lished, but  the  supply  was  not  abundant  and  the  child 
did  not  get  as  much  narcotic  through  the  milk  as  it  had 
been  accustomed  to  before  birth,  and  it  was  found  neces- 
sary, in  order  to  keep  the  child  free  from  abstinence 
symptoms,  to  supplement  it  by  the  administration  of  2 
drops  of  laudanum  three  times  a  day. 

When  the  child  was  a  few  weeks  old  an  effort  was 
made  to  discontinue  these  doses  and  depend  upon  the 
supply  from  the  milk  alone,  but  the  child  was  very 
fretful  and  restless  when  these  doses  were  not  given,  so 
it  was  thought  best  to  continue  them  until  the  mother 
and  child  could  be  sent  for  treatment.  This  was  done 
when  the  child  was  two  months  old. 

Upon  admission  the  mother  was  found  to  be  using 
about  10  grains  morphine  daily;  the  infant  was  nursing 
and  receiving,  in  addition  to  the  quantity  it  obtained 
from  the  milk,  from  6  to  9  drops  of  laudanum  daily. 
Both  were  prepared  for  withdrawal  by  thorough  elimi- 
nation, devoting  three  days  to  this  part  of  the  treatment, 
and  the  opiate  was  discontinued  at  once  in  both  cases. 

The  mother  was  kept  under  the  influence  of  hyoscine 
to  a  moderate  degree  for  a  couple  of  days  and  the 
child  was  allowed  to  continue  to  nurse.  Within  six 
hours  from  the  time  the  administration  of  hyoscine  to 
the  mother  was  begun,  the  child  showed  distinct  signs  of 
the  effects  of  that  remedy,  but  it  was  fretful  and  mani- 
festly uncomfortable.  At  this  time  a  dose  of  Viooo  grain 
hyoscine  was  given  to  the  baby,  and  this  dose  was  re- 


328  Narcotic  Drug  Diseases  and  Allied  Ailments. 

peated  every  four  to  six  houi  s  for  the  succeeding  thirty- 
six  hours. 

By  the  end  of  the  third  day  from  the  withdrawal, 
both  patients  were  fairly  out  from  under  the  influence 
of  hyoscine  and  all  other  remedies  and  were  comfortable. 
On  the  fourth  day  their  condition  was  still  more  satis- 
factory, and,  from  that  time  on,  their  convalescence  was 
normal  and  uninterrupted.  Neither  of  them  suffered 
during  the  treatment  to  such  a  degree  as  to  show  it. 

The  doctor,  the  husband  and  father,  writes  under 
date  of  Nov.  4,  1911,  saying  that  both  mother  and  child 
are  in  good  health  and  free  from  their  addiction.  He 
sends  picture  of  the  little  girl,  who  is  now  a  hearty, 
robust  child  of  2  years 

Every  child  born  of  an  opium-using  mother  should 
be  given  an  opiate  for  the  first  three  days  after  birth. 
After  that  the  milk  may  be  depended  upon  to  contain 
enough  of  the  drug  to  satisfy  the  demands  of  the  child's 
system,  or,  if  it  is  thought  best  not  to  allow  the  child  to 
nurse,  the  administration  of  the  opiate  should  be  con- 
tinued until  such  time  as  the  child  is  strong  enough  to 
stand  the  withdrawal.  By  this  means  their  lives  can  be 
preserved. 

The  quantity  of  opiate  which  the  child  will  require  to 
relieve  its  distress  and  to  bring  it  up  to  what  to  it  is  a 
normal  condition  will  vary  according  to  the  quantity  of 
drug  which  is  being  taken  by  the  mother.  The  child's 
blood  is  as  much  saturated  with  the  narcotic  as  is  the 
blood  of  the  mother,  and  the  nerve-centers  have  acquired 
the  same  proportionate  degree  of  tolerance  for  the  opiate 
that  the  mother's  nervous  system  has. 

The  relative  size  of  the  dose,  however,  will  not  hold 
good  if  the  mother  is  taking  more  than  10  grains  of 
morphine  per  day.  It  is  not  believed  that  the  system 


Excessive   Quantities  Not  Appropriated.  329 

will  really  appropriate  more  than  15  or  20  grains  of 
morphine  per  day  at  the  outside,  and  probably  not  much 
over  10  grains.  What  is  taken  in  excess  of  that  amount 
is  really  thrown  off  as  waste  and  makes  but  little,  if  any, 
impression  on  the  nervous  system. 

A  drug  habitue  who  is  taking  regularly,  and  whose 
system  has  become  accustomed  to  the  effects  of,  as  much 
as  20  grains  of  morphine  per  day  could  inject  almost  any 
quantity  above  that  with  impunity.  However,  if  the 
mother  is  taking  only  a  few  grains,  or  even  I  grain,  of 
morphine  daily,  the  child's  system  will  be  equally  as 
toxic  from  its  effects  as  that  of  the  mother  and  the  drug 
will  be  as  much  a  necessity  to  its  comfort  as  it  is  to  the 
comfort  of  the  mother. 

While  it  will  not  require  so  large  a  dose  for  a  child 
born  to  a  mother  who  is  using  only  a  small  quantity  of 
opiates  per  day,  the  opiate  is  necessary  to  its  comfort  and 
its  administration  should  be  begun  as  soon  as  abstinence 
symptoms  make  their  appearance.  It  is  a  safe  rule  to 
begin  with  I  drop  of  laudanum  and  repeat  at  intervals 
of  one-half  hour  until  the  child  shows  the  effects  of  the 
drug,  either  by  being  put  to  sleep  or  being  relieved  from 
the  distressing  abstinence  symptoms. 

The  time  that  these  symptoms  may  be  expected  to 
show  themselves  will  depend  upon  the  frequency  with 
which  the  mother  has  been  in  the  habit  of  taking  the 
doses  of  her  drugs.  If  the  mother  is  taking  but  one  dose 
of  opiate  in  twenty-four  hours  and  the  child  is  born  a 
few  hours  after  she  has  had  her  accustomed  dose,  of 
course,  its  blood  will  have  in  it  the  proportionate  quan- 
tity of  the  opiate,  and  this  will  continue  to  keep  the  child 
quiet  until  the  time,  or  probably  a  few  hours  beyond  the 
time,  for  the  succeeding  dose  to  which  the  mother  has 
been  accustomed. 


330  Narcotic  Drug  Diseases  and  Allied  Ailments. 

But  should  the  child  be  born  just  before  the  time  for 
the  mother's  accustomed  dose,  it  is  evident  that  her  blood 
and  her  system,  as  also  that  of  the  child,  would  be  fairly 
well  out  from  under  the  influence  of  the  dose  taken,  say, 
eighteen  or  twenty  hours,  or  probably  twenty-three 
hours,  before.  In  this  case  the  child  would  begin  to 
suffer  from  the  abstinence  symptoms  within  a  very  short 
time  after  delivery,  notwithstanding  only  one  dose  of 
morphine  had  been  taken  by  the  mother  during  each 
twenty-four  hours. 

This  condition  should  be  inquired  into,  and,  if  the 
mother  has  taken  her  accustomed  dose  only  a  few  hours 
before  the  severance  of  placental  circulation,  no  opiate 
will  be  required  for  the  child  until  the  succeeding  time 
for  the  mother's  dose;  then  it  should  be  given  the  child, 
as  well  as  the  mother. 

Again,  the  frequency  with  which  the  child  will  re- 
quire these  doses  will  depend  upon  the  frequency  with 
which  the  mother  has  been  accustomed  to  taking  the 
drug.  The  child's  nerve-centers  have  been  accustomed 
to  the  same  periodic  narcotic  sedation  which  the  mother 
has  been  subjected  to,  and  these  periods  have  become 
fixed  in  its  life  to  such  a  degree  that  if  the  narcotic 
impression  to  which  it  has  thus  been  accustomed  is  not 
kept  up  the  child  will  suffer  abstinence  symptoms,  just 
as  the  mother  would  if  she  did  not  receive  her  accus- 
tomed dose  at  the  time  she  had  been  taking  it. 

These  periods  should  be  observed  in  the  administra- 
tion of  the  drug  to  the  child,  as  well  as  the  mother,  as 
any  attempt  to  interfere  with  them  at  this  stage  would 
result  in  serious  illness  of  the  child.  When  the  child  is 
two  or  three  months  old,  both  the  child  and  mother  may 
be  safely  taken  off  the  drug  by  proper  treatment,  but 
no  effort  at  withdrawal  or  even  reduction  of  the  drug 


Child  in  Utcro,  an  Habitue.  331 

should  be  made  during  the  parturient  month,  either  in 
the  case  of  the  child  or  mother. 

The  results  obtained  by  two  mothers  who  have  come 
under  the  author's  care  show  the  importance  of  adminis- 
tering an  opiate  to  the  child  from  the  time  of  birth  until 
the  flow  of  milk  is  established. 

Mrs.  M.  J.  came  for  treatment  May,  1910.  She  had 
been  taking  McMunn's  elixir  of  opium  thirty-one  years. 
Is  the  mother  of  eighteen  children;  only  the  first  two 
and  the  last  one  lived  beyond  the  third  day  after  birth. 
The  first  two  children  were  born  before  she  became  ad- 
dicted to  the  opiate.  During  the  third  pregnancy  she 
was  threatened  with  miscarriage  and  McMunn's  elixir  of 
opium  was  given  to  prevent  it.  During  the  last  half  of 
the  period  of  gestation,  the  opiate  was  administered  to 
her  two  or  three  times  a  day,  and,  while  it  served  the 
purpose  of  preserving  the  pregnancy,  it  also  fastened 
the  opium  habit  upon  her  and  she  was  not  able  to  throw 
it  off. 

The  child  was  fully  developed  and  apparently  per- 
fectly healthy,  but  on  the  day  following  its  birth  it  began 
to  show  signs  of  illness  and  it  grew  progressively  worse 
and  died  forty-eight  hours  after  delivery  in  convulsions. 
Neither  the  physician  in  attendance  nor  the  mother 
understood  the  necessity  of  giving  the  child  an  opiate, 
and  none  was  given;  the  death  was  attributed  to  un- 
known causes. 

This  pregnancy  was  followed  by  another  within 
fifteen  months,  in  which  she  was  confined  under  the  same 
management,  with  death  of  the  child  within  three  days 
after  birth,  and  this  pregnancy  by  another  and  another, 
until  this  woman  had  given  birth  to  fifteen  children  while 
using  an  opiate  habitually. 

All  the  children  died  within  three  days  from  their 
birth,  most  of  them  dying  by  the  end  of  the  second  day. 


332  Narcotic  Drug  Diseases  and  Allied  Ailments. 

The  same  physician  attended  her  in  all  these  confine- 
ments, and  both  the  mother  and  the  physician  looked 
upon  the  death  of  the  children  as  a  natural  consequence 
of  the  mother's  condition  and  inevitable. 

In  her  last  confinement  she  was  attended  by  another 
physician,  who  appreciated  the  conditions  under  which 
the  child  was  being  brought  into  the  world  and  under- 
stood the  necessity  of  protecting  it  from  the  shock  inci- 
dent to  the  abrupt  withdrawal  of  the  opiate.  In  order 
to  do  this  he  gave  paregoric  in  lo-drop  doses  and  these 
were  repeated  at  such  intervals  as  was  found  necessary 
to  keep  the  child  comfortable  and  free  from  abstinence 
symptoms. 

The  child  was  not  allowed  to  nurse,  but  the  paregoric 
was  kept  up  for  a  few  months  and  then  gradually  dis- 
continued. This  child  is  now  a  stout,  healthy  boy  of  13 
years,  and  the  mother  is  firm  in  her  belief  that,  had  the 
same  course  been  pursued  with  her  other  children,  they 
would  have  lived  also.  They  were  all  well  developed  and 
apparently  normal  children  and  showed  no  signs  of 
illness  or  discomfort  during  the  first  twelve  hours  after 
birth,  but,  from  that  time  on,  their  illness  grew  rapidly 
and  they  either  went  into  complete  collapse  or  died  in 
convulsions  by  the  end  of  the  third  day  after  birth. 

Another  case,  treated  in  1911,  gives  a  history  which 
in  some  particulars  is  very  similar  to  the  above,  while 
in  others  it  differs  greatly.  This  woman,  Mrs.  C.  J.  D., 
had  been  using  morphine  by  the  mouth  forty-five  years ; 
during  most  of  that  time  she  had  taken  with  regularity 
20  grains  of  morphine  per  day.  She  was  married  in 
1863;  first  child  in  1864,  premature,  at  sixth  month  of 
pregnancy. 

'A  second  pregnancy  soon  followed,  which  resulted 
in  miscarriage  at  third  month.  The  third  pregnancy 


Management  of  Infant.  333 

occurred  in  1866.  Miscarriage  was  threatened  at  second 
month  and  morphine  was  administered  to  preserve  the 
conception.  This  was  used  occasionally  to  relieve  symp- 
toms for  the  first  few  months,  but  before  gestation  was 
completed  the  drug  had  been  used  daily  for  more  than 
three  months,  by  which  the  morphine  addiction  was 
established,  but  she  was  carried  to  full  term  and  de- 
livered of  a  normal  child. 

The  mother  says  that,  either  from  intuition  or  upon 
the  advice  of  the  midwife  who  attended  her,  paregoric 
was  administered  to  the  child  when  it  became  fretful, 
and  this  was  kept  up  for  several  months  before  it  was 
entirely  discontinued;  the  child  lived  to  be  a  grown 
woman. 

After  the  mother's  recovery  from  this  confinement  an 
effort  was  made  to  discontinue  the  use  of  the  morphine, 
but  without  success,  and  its  use  has  been  continued  from 
that  time  on. 

As  she  did  not  allow  this  child  to  nurse,  another 
pregnancy  occurred  within  a  year,  and  this  was  followed 
by  others  in  rapid  succession  until  eleven  children  had 
been  born  to  this  morphine-using  mother.  She  went  to 
full  term  with  all  of  them  and  none  of  the  children  died 
in  infancy ;  six  of  them  are  now  living,  and  none  of  them 
show  peculiarities  which  could  be  attributed  to  the  condi- 
tion of  the  mother  at  the  time  of  their  birth. 

The  same  course  was  pursued  in  the  case  of  the  last 
ten  children  as  in  that  of  the  first  one  that  lived.  An 
opiate  was  administered  to  them  on  the  day  following 
their  birth,  usually  about  twelve  hours  after  birth.  The 
mother  says  that  about  twelve  hours  after  birth  they 
began  to  show  signs  of  discomfort  and,  as  she  under- 
stood what  these  symptoms  meant,  she  administered  an 
opiate,  and  this  was  repeated  at  such  intervals  as  was 


334  Narcotic  Drug  Diseases  and  Allied  Ailments. 

found  necessary,  and  after  the  babies  were  a  few  months 
old  the  opiate  was  discontinued  by  gradual  reduction, 
and  this  was  usually  done  without  very  much  difficulty. 
None  of  the  children  were  allowed  to  nurse. 

One  unique  feature  of  this  case  is  that  no  menstrual 
flow  occurred  after  the  third  pregnancy;  at  that  time 
the  morphine  addiction  became  established,  and  the 
ten  conceptions  following  that  occurred  without  the 
appearance  of  menstruation  at  all.  As  a  rule,  the  habit- 
ual use  of  opiates  arrests  menstruation,  but  from  these 
cases  it  is  quite  evident  that  it  does  not  always  arrest 
ovulation,  if,  indeed,  it  does  so  at  all. 

The  earlier  writers  on  drug  addiction  assert  that  the 
habitual  use  of  opiates  not  only  suspends  menstruation, 
but  arrests  ovulation  as  well.  This  opinion  was  evidently 
erroneous,  as  it  is  now  known  that  several  hundred 
children  are  born  annually,  in  the  United  States  alone, 
to  women  who  use  opiates  habitually.  The  lives  of  these 
children  can  be  preserved  by  following  the  plan  herein 
outlined,  but  without  such  precautions  very  few  of  them 
live. 

CONCEALED  MORPHINISM  IN  PARTURIENT 
WOMEN. 

When  a  child  is  born  of  a  woman  whose  habits  are 
not  known  and  the  child  appears  to  be  healthy  and 
normal  in  every  respect  at  birth,  but  in  the  course  of  six 
to  eighteen  hours  afterward  begins  to  show  signs  of 
discomfort,  the  symptoms  taking  the  form  of  gastro- 
intestinal disturbances,  with  embarrassed  portal  circula- 
tion, which  symptoms  grow  progressively  more  notice- 
able from  hour  to  hour,  concealed  narcotic  addiction  in 
the  mother  should  be  suspected  and  evidence  of  the  exist- 
ence of  such  condition  diligently  searched  for. 

Narcotic  addiction  in  the  mother  will  often  be  found 
to  explain  this  sudden,  and  otherwise-unaccounted-for, 


Treatment  of  Morphinism  in  Infancy.  335 

illness  of  the  infant.  When  this  condition  of  affairs  is 
suspected,  although  the  mother  may  not  admit  it,  it  is 
well  to  give  the  child  an  opiate,  say,  I  drop  of  laudanum. 
If  this  shows  less  than  the  normal  effect,  repeat  it  in 
half  an  hour,  watch  for  effect  again,  and  if  not  seen 
repeat  again,  and  continue  to  do  so  until  the  child  is 
brought  fairly  well  under  the  influence  of  the  opiate,  or 
until  it  is  restored  to  the  apparently  normal  condition 
which  existed  for  the  time  immediately  succeeding  its 
birth. 

If  the  child  is  found  to  have  an  undue  tolerance  for 
the  opiate  or  if  its  effects  restore  an  apparently  normal 
condition  instead  of  inducing  narcotic  sleep,  the  exist- 
ence of  narcotic  addiction  may  be  accepted  as  a  fact  and 
the  case  handled  accordingly.  If  it  is  a  narcotic  case, 
as  the  effects  of  the  narcotic  administered  begin  to 
wane,  the  symptoms  of  distress  will  again  make  their 
appearance  and  nothing  but  a  narcotic  will  relieve  them. 
This  should  be  given  as  in  cases  where  addiction  is  ad- 
mitted. Few  mothers,  however,  will  be  found  to  stub- 
bornly persist  in  denying  their  real  condition  when  they 
are  made  to  realize  that  the  life  of  their  child  may  de- 
pend upon  their  making  their  real  condition  known,  at 
least  to  the  attending  physician. 


CHAPTER  XVII. 

THE    TREATMENT    OF    ACUTE   AILMENTS    OCCUR- 
RING IN  PERSONS  ADDICTED  TO  HABITUAL 
USE   OF   NARCOTIC   DRUGS. 

THE  fact  that  death  is  almost  certain  to  be  the  result 
of  an  acute  ailment  such  as  typhoid  fever,  pneumonia,  or 
dysentery  when  these  ailments  occur  in  one  who  is  ad- 
dicted to  the  habitual  use  of  a  narcotic  drug  suggests 
an  inquiry  as  to  the  reason  for  this  high  mortality. 

Every  internist  is  occasionally  called  upon  to  treat 
acute  ailments  of  various  kinds  occurring  in  persons  ad- 
dicted to  the  use  of  narcotics,  and  in  such  persons  these 
ailments  present  some  very  knotty  problems,  which  they 
do  not  present  when  they  occur  in  persons  not  so  ad- 
dicted. 

Therefore,  it  is  well  to  ask  in  what  way  and  to  what 
extent  does  the  habitual  use  of  the  narcotic  modify  the 
acute  ailment?  Does  it  increase  or  decrease  its  severity? 
To  what  extent  and  in  what  manner  will  the  habitual 
use  of  the  narcotic  modify  or  interfere  with  the  action 
of  the  remedies  used  in  the  treatment  of  the  acute  ail- 
ment? How  will  it  affect  the  prognosis?  Shall  the 
narcotic  be  continued  or  withheld  during  the  treatment 
of  the  acute  ailment?  If  continued,  how?  If  discon- 
tinued, how  is  that  to  be  done? 

These,  as  well  as  other  equally  perplexing,  questions 
confront  everyone  who  is  called  upon  to  treat  patients 
of  this  class  when  attacked  by  an  acute  ailment,  and  his 
success  in  such  an  undertaking  depends  on  his  ability  to 
solve  these  problems. 

In  order  to  find  answers  to  these  questions  it  is  neces- 
sary to  consider  the  effect  morphine  has  on  the  system. 
(336) 


Elimination,   Difficulty  in  Securing.  337 

At  the  very  beginning  of  its  use,  the  first  dose  brings 
about  a  state  of  quietude  or  torpor  accompanied  by  the 
diminished  excretions  of  the  products  of  waste.  In  the 
course  of  from  twelve  to  twenty-four  hours,  these  effects 
of  the  drug  subside  and  the  functional  activity  of  the 
system  becomes  normal. 

Or,  possibly  excretion  is  carried  on  at  an  accelerated 
rate,  but  it  requires  several  days  for  this  increased 
activity  of  the  excreting  organs  to  free  the  system  from 
the  products  of  waste  which  should  have  been  excreted 
during  the  time  these  functions  were  restrained  by  the 
effects  of  the  narcotic. 

Now,  if  before  this  is  accomplished  another  dose  is 
taken,  the  eliminating  organs  are  again  interfered  with 
in  their  work,  resulting  in  retention  of  the  product  of 
waste.  In  the  drug  habitue  these  doses  are  repeated 
from  day  to  day,  usually  several  times  a  day,  thus  con- 
stantly interfering  with  the  work  of  the  excreting 
organs,  and  the  system  soon  becomes  surcharged  with 
the  product  of  tissue  disintegration  and  their  fermenta- 
tive compounds.  In  other  words,  the  habitual  condition, 
the  normal  state  as  it  were,  of  the  drug  habitue  is  one  of 
profound  toxemia.  These  toxins  are  of  intestinal,  drug, 
and  auto-  origin. 

Any  acute  ailment  occurring  in  one  whose  system  is 
in  such  a  toxic  condition  is  greatly  intensified.  Fever, 
pain,  and  all  other  symptoms  are  increased  in  severity, 
and  if  the  attack  be  of  an  inflammatory  type  the  inflam- 
mation is  likely  to  partake  of  an  erysipelatous  nature 
and  spread  with  great  rapidity.  In  all  such  cases  the 
prognosis  is  extremely  grave. 

The  treatment  of  such  a  condition  is  manifestly  diffi- 
cult, since  the  narcotic  drug  must  be  continued.  If  the 
drug  could  be  discontinued  the  eliminating  organs  could 


22 


338  Narcotic  Drug  Diseases  and  Allied  Ailments. 

be  readily  brought  into  play  and  the  toxic  matter  thrown 
off,  but  any  attempt  to  withdraw  the  drug  at  the  begin- 
ning of,  or  during,  an  acute  ailment  would  precipitate  a 
crisis  which  would  almost  certainly  end  in  death. 

Therefore,  the  physician  is  confronted  with  the 
necessity  of  curing  the  acute  ailment,  of  overcoming  a 
diseased  condition,  while  its  cause  continues  in  active 
operation.  Not  only  that,  but  if  the  patient  is  left  to  his 
own  volition  in  the  matter  he  will  take  his  drug  in  in- 
creased quantities  in  order  to  partially  overcome  the 
distress  incident  to  the  acute  ailment,  and  this  would 
still  farther  retard  secretion  and  excretion. 

In  order  to  have  a  rational  basis  for  the  application 
of  the  therapeutic  measures  with  which  to  combat  this 
condition,  a  conclusion  should  be  reached  as  to  which 
of  the  excreting  or  secreting  organs  is  materially  inter- 
fered with  and  what  is  the  extent  and  character  of  that 
interference. 

The  action  of  the  kidneys  is  not  materially  affected, 
since  about  as  large  a  per  cent,  of  urea  and  other  excre- 
tory products  are  thrown  off  by  the  kidneys  of  the  drug 
habitue  as  by  a  normal  person  and  the  quantity  of  liquid 
passed  is  practically  normal. 

The  action  of  the  peptic  and  pancreatic  glands  does 
not  seem  to  be  materially  affected.  A  morphine  habitue 
can  digest  and  assimilate  as  large  a  quantity  of  nourish- 
ment under  the  effects  of  morphine  as  he  can  without 
it,  if  the  system  is  in  equally  toxic  condition  from  any 
other  cause.  In  other  words,  while  they  are  anemic  and 
their  tissues  are  poorly  nourished  and  digestion  and 
assimilation  are  interfered  with,  these  interferences  are 
due  to  the  toxic  condition  of  the  system  rather  than  to 
any  direct  effect  that  the  morphine  has  on  the  digestive 
organs  themselves. 


Motor  Function  Chiefly  Impaired.  339 

The  action  of  the  liver  does  not  seem  to  be  materially 
affected.  Drug  users  are  able  to  eat  and  digest  fair 
quantities  of  fats,  and  bile  may  be  found  in  the  stool. 
Since  it  is  not  apparent  that  the  action  of  either  of  these 
classes  of  secreting  and  excreting  glands  is  affected  to 
such  a  degree  as  to  account  for  the  extremely  toxic  con- 
ditions present,  is  it  to  be  presumed  that  the  remaining 
set,  the  excreting  glands  of  the  intestines,  are  entirely 
at  fault? 

Not  necessarily.  Their  action  is  regulated  by  the 
same  nerve-centers  which  preside  over  the  activity  of 
the  other  intestinal  glands.  Their  action  could  hardly 
be  suspended  to  such  a  degree  as  to  account  for  the  toxic 
condition  present  without  more  marked  derangement  of 
the  other  glands  having  the  same  nerve  supply. 

This  leaves  the  blame  to  rest  on  the  other  excre- 
tory force,  the  motor  function  of  the  bowel.  It  is  here 
that  the  chief  trouble  is  found. 

One  of  the  earliest  and  most  noticeable  effects  of 
morphine  is  to  arrest  intestinal  motion.  In  a  very  short 
time  from  the  administration  of  a  full  dose  of  morphine 
peristalsis  is  completely  arrested  and  remains  absent  for 
a  period  varying  from  four  to  twelve  hours,  depending 
upon  the  size  of  the  dose. 

In  drug  habitues  these  doses  are  repeated  at  frequent 
intervals  and  peristalsis  is  suspended  during  a  greater 
part  of  each  twenty-four  hours.  Peristalsis  is  essential 
to  the  discharge  of  waste  from  the  bowels.  A  motionless 
canal  means  a  clogged  canal.  The  eliminating  organs 
may  be  likened  to  a  sewer  system,  with  the  intestinal 
canal  as  the  main  and  the  ducts  of  the  excreting  glands 
as  the  laterals. 

Since  the  laterals  cannot  discharge  their  waste  into 
an  already  overfilled  main,  it  is  retained  or  forced  back 


340  Narcotic  Drug  Diseases  and  Allied  Ailments. 

into  the  system.  The  reabsorption  of  this  waste  from 
the  clogged  or  sluggish  excreting  stream  is  the  mecha- 
nism by  which  the  system  of  the  drug  user  becomes 
toxic.  When  this  semiparalyzed  condition  of  the  intes- 
tinal canal  is  overcome  and  active  motility  established  in 
its  stead,  the  accumulated  waste  is  promptly  discharged. 

The  fact  that  when  active  peristalsis  is  induced  and 
maintained  very  little,  if  any,  larger  quantities  of  the 
secretory  stimulants  are  required  to  secure  free  move- 
ments from  the  bowel  of  a  drug  habitue  than  from  one 
who  is  not  using  the  drug  confirms  the  author  in  the 
belief  that  the  functional  activity,  per  se,  of  the  secreting 
and  excreting  glands  is  not  materially  reduced,  but  that 
the  failure  of  excretion  arises  almost  exclusively  from 
suspension  of  the  motor  function  of  the  bowel. 

Fortunately,  there  is  one  drug  in  our  armamen- 
tarium which  has  sufficient  power  to  bring  about  free 
intestinal  motion  notwithstanding  the  restraining  effects 
of  the  opium,  provided  it  is  given  in  sufficient  doses  and 
at  the  proper  time. 

That  drug  is  strychnine.  Ordinary  medicinal  doses, 
however,  are  not  sufficient.  In  estimating  the  quantity 
of  strychnine  required  in  any  given  case,  age,  weight, 
and  physique  of  the  patient  must  be  taken  into  considera- 
tion, as  well  as  the  quantity  of  morphine,  the  paralyzing 
effects  of  which  are  to  be  overcome. 

Young  persons  are  more  susceptible  to  strictures 
than  older  ones.  The  short,  compactly  built  in  whom 
a  fair  degree  of  muscular  tone  is  present  do  not  require 
as  much  as  the  tall,  loose-jointed  with  flabby  tissues,  but 
the  relation  between  the  time  of  giving  the  strychnine 
and  the  morphine,  the  effects  of  which  are  to  be  neutra- 
lized, is  equally  as  important  as  the  size  of  the  dose. 

Strychnine  excites  peristalsis  by  direct  stimulation  of 
the  motor  centers.  Motor  waves  thus  induced  extend  to 


Elimination,  Method  of  Securing.  341 

all  the  structures  which  would  receive  them  if  the  centers 
were  acting  normally  or  without  artificial  stimulation. 

The  arrest  of  the  intestinal  motion  by  morphine  is 
most  marked  during  the  primary  effect  of  each  dose,  but, 
as  the  primary  effects  of  the  drug  wear  away,  peristalsis 
gradually  becomes  active.  Drug  users,  as  a  rule,  take 
their  drugs  only  during  the  day,  or  from  the  time  of 
rising  in  the  morning  until  bedtime,  say,  from  8  A.M.  to 
10  P.M.  During  these  hours  the  system  is  kept  con- 
stantly under  the  primary  effects  of  the  drug,  and  intes- 
tinal motion  is  very  much  restricted,  but  during  the 
period  between  10  P.M.  and  8  A.M.  the  effects  of  the 
day's  dosing  wear  away,  and  peristalsis  becomes  fairly 
active.  It  is  during  the  latter  part  of  this  period  that 
the  excretory  organs  do  the  principal  part  of  their  work. 

In  order  to  secure  prompt  action  of  purgatives  ad- 
vantage must  be  taken  of  this  state  of  affairs.  The 
remedies  must  also  be  so  compounded  and  be  given  at 
such  times  as  to  have  the  acme  of  their  effects,  both  as 
motor  and  secretory  stimulants,  occur  during  that  part 
of  this  period  when  the  system  is  least  under  the  re- 
straining influence  of  the  opium. 

To  do  this,  begin  with  a  purgative  course  at  2  P.M. 
and  give  on  an  empty  stomach  a  dose  every  two  hours 
until  10  P.M.  For  an  average  person  taking  5  or  more 
grains  of  morphine  per  day,  the  following  will  be  found 
effective : — 

1$  Calomel, 

Extract  of  cascara aa  gr.  x. 

Ipecac  gr.  j. 

Atropine  sulphate gr.  %0- 

Strychnine  nitrate gr.  %. 

Mix  and  make  5  capsules ;  write,  one  at  2,  4,  6,  8,  and  10  P.M. 

It  will  be  noticed  that  these  capsules  contain  ^o 
grain  of  strychnine  each,  and  that  I  is  to  be  given  every 


342  Narcotic  Drug  Diseases  and  Allied  Ailments. 

two  hours  until  5  such  doses  are  given,  making  %  grain 
of  strychnine  in  eight  hours.  These  would  be  excessive 
doses  for  one  not  under  the  influence  of  an  opiate,  but  it 
must  be  remembered  that  morphine  opposes  strychnine 
in  most  all  of  its  range  of  action,  and  that  it  is  necessary 
to  overcome  its  paralyzing  action  on  the  motor  function 
of  the  bowel. 

Unless  a  quantity  sufficient  to  do  this  is  given,  the 
secretory  stimulants  given  with  it  will  simply  stir  up  a 
storm  in  the  upper  parts  of  the  intestinal  canal,  accom- 
panied by  nausea,  vomiting,  other  distress,  but  no  bowel 
action  will  occur.  It  is  more  than  likely  that  this  storm 
would  have  to  be  allayed  by  an  increased  dose  of  the 
opium. 

During  the  time  these  purgative  capsules  are  being 
given,  the  patient  should  have  his  usual  dose  of  mor- 
phine, but  none  must  be  given  from  the  time  of  giving 
his  last  purgative  capsule  until  free  evacuations  have 
been  obtained.  The  physician  should  take  charge  of  the 
patient's  drug  supply  at  the  time  of  beginning  the  purga- 
tive course  and  control  it  from  that  time  on.  If  left  to 
himself  he  will  take  a  dose  at  an  inopportune  time  and 
thus  delay  or  prevent  the  action  of  the  purgative. 

The  strychnine  and  atropine  in  these  capsules  will 
excite  a  fair  degree  of  peristalsis  notwithstanding  the 
restraining  effects  of  the  opium,  and  this  will  usually 
enable  the  secretory  stimulants  given  with  them  to  in- 
duce free  evacuation  from  the  bowel  in  eight  or  ten 
hours  from  the  time  of  giving  the  last  purgative  capsule, 
thus  securing  bowel  movements  before  the  time  for  the 
next  dose  of  opiate. 

But  more  certainly  to  accomplish  this  result,  six 
hours  from  the  time  of  giving  the  last  purgative  capsule, 
give  %o  grain  of  strychnine  hypodermically  and  follow 


Elimination  Must  be  Thorough.  343 

in  half  an  hour  with  2  ounces  of  castor  oil  or  full  dose 
of  salts,  and  repeat  both  the  strychnine  and  the  oil  or 
salts  at  intervals  of  two  hours  until  the  intestinal  canal 
is  thoroughly  empty. 

If  the  bowels  begin  to  act  before  the  time  of  the 
usual  morning  dose  of  the  morphine,  the  patient  will 
experience  little,  if  any,  discomfort ;  but  if  not,  the  opiate 
must  be  withheld  until  the  bowel  has  been  emptied. 
This  may  be  a  stormy  period,  but  the  storm  must  be 
weathered. 

If  the  ingredients  of  the  purgative  course  and  the 
strychnine  have  been  properly  adjusted  to  the  case  in 
hand,  the  bowel  will  begin  to  act  in  six  or  eight  hours 
from  the  time  of  giving  the  last  purgative  capsule  and 
a  number  of  free  evacuations  will  have  been  obtained 
before  the  time  for  giving  the  morning  dose  of  morphine. 
The  relief  afforded  by  this  active  elimination  is  usually 
such  as  to  enable  the  patient  to  go  in  comfort  several 
hours  beyond  the  time  for  his  morning  dose  of  opium, 
and  if  he  can  he  should  do  this,  thus  allowing  more  time 
for  elimination. 

When  the  patient  has  gone  without  his  dose  of  opium 
as  long  as  he  can  without  discomfort,  give  it  to  him,  but 
in  reduced  quantity.  It  will  be  found  that,  after  the 
bowel  has  been  thoroughly  emptied  and  the  patient  has 
gone  without  the  opiate  several  hours  beyond  the  usual 
time  for  his  dose,  not  more  than  half  the  quantity  of 
morphine  which  he  had  been  taking  will  be  required  to 
meet  the  demands  of  the  system.  This  quantity  should 
be  given  at  regular  intervals,  observing  the  hours  at 
which  he  had  been  accustomed  to  taking  his  dose. 

Forty-eight  hours  from  the  time  the  first  purgative 
course  was  begun  another  should  be  started  and  given 
as  the  first.  This  course  may  be  less  or  more  active 


344  Narcotic  Drug  Diseases  and  Allied  Ailments. 

according  to  the  effects  obtained  from  the  first  one.  It 
should  be  followed  by  strychnine  and  salts  or  oil,  as  in 
the  first  instance. 

This  course  carries  into  and  out  of  the  intestinal 
canal  a  residue  of  extremely  toxic  matter  and  the  relief 
obtained  from  it  is  even  more  marked  than  from  the 
first.  After  its  action  a  smaller  quantity  of  morphine 
will  meet  the  demand  of  the  system  than  after  the  first 
course,  but  whatever  quantity  may  be  found  necessary 
to  keep  the  patient  free  from  abstinence  symptoms 
should  be  given,  and  this  should  be  continued  at  regular 
intervals  throughout  the  remainder  of  the  acute  ailment. 

Following  the  second  purgative  course,  the  bowel 
should  be  kept  active  by  the  regular  and  persistent  ad- 
ministration both  of  a  motor  and  secretory  stimulant, 
and  thus  a  recurrence  of  intestinal  toxemia  be  prevented. 
From  !/4Q  to  %o  grain  of  podophyllin  or  20  grains  of 
sodium  hyposulphite  given  at  intervals  of  from  two  to 
four  hours  during  the  remainder  of  the  acute  ailment 
will  usually  answer  the  purpose  admirably,  but  these 
only  meet  the  demand  for  a  secretory  stimulant. 

To  insure  the  activity  of  the  other  function  which  is 
essential  to  bowel  movement,  a  sufficient  quantity  of 
strychnine  should  be  given  during  the  evening  hours  of 
each  day  to  excite  active  peristalsis. 

With  elimination  thus  efficiently  secured  by  stimula- 
tion of  both  the  motor  and  secretory  functions  of  the 
bowel  and  with  the  same  kept  active  during  the  re- 
mainder of  the  acute  ailment,  that  ailment,  whatever  it 
is,  can  be  treated  with  but  little  more  difficulty  and  with 
about  as  much  success  as  if  there  were  no  drug  addiction 
present. 

It  is  a  great  mistake  to  attempt  to  reduce  the  quantity 
of  drug  a  patient  of  this  class  is  taking  during  an  acute 
ailment,  except  as  above  noted. 


Proportionate  Stimulation  of  Functions.  345 

Any  attempt  at  gradual  reduction  of  the  dose  will 
only  aggravate  the  symptoms  of  the  acute  ailment,  in- 
crease the  fever,  make  the  patient  more  restless,  and 
cause  him  to  suffer  unnecessarily,  and  without  benefit. 

The  quantity  of  the  drug  taken  does  not  make  much 
difference,  but  it  is  material  that  the  system  shall  be  kept 
free  from  toxic  matter.  If  the  bowels  are  allowed  to 
become  clogged,  the  reabsorption  of  intestinal  contents 
occurs  and  this  will  aggravate  all  the  symptoms  of  any 
ailment,  and  especially  of  any  inflammatory  ailment, 
with  which  the  patient  may  be  suffering. 

It  is  unwise  to  depend  upon  the  action  of  secretory 
stimulants  alone  to  keep  up  bowel  action.  The  motor 
function  of  the  bowel  is  just  as  essential  to  bowel  move- 
ment as  the  secretory  function  of  the  glands,  and  this 
should  be  efficiently  provided  for  by  direct  stimulation  of 
the  motor  centers. 

The  effects  of  the  opiate  in  paralyzing  the  motor 
function  of  the  bowel  is  so  marked  and  so  persistent  that 
reflex  action  alone  cannot  be  depended  upon  to  provide 
this  essential  function  to  bowel  movement. 

Again,  if  all  the  functions  concerned  in  the  evacua- 
tion of  waste  be  stimulated  proportionately  and  at  the 
proper  time,  bowel  evacuation  can  be  induced  without 
exhausting  the  patient ;  but  if  we  stimulate  the  secretory 
functions  of  the  bowel  excessively  and  depend  upon  its 
reflex  influence  to  excite  the  other  essential  function,  we 
shall  have  created  such  great  activity  of  the  excretory 
glands  as  to  be  exhausting  when  action  does  occur,  and 
this  would  materially  weaken  the  patient. 

But  if  all  the  functions  be  stimulated  proportionately, 
evacuation  of  the  bowel  can  be  secured  without  weak- 
ening the  patient.  In  fact,  he  will  be  better  off  while 
having  his  bowel  regularly  moved. 


346  Narcotic  Drug  Diseases  and  Allied  Ailments. 

If  the  bowel  is  much  constipated  it  will  be  well  to 
empty  the  lower  bowel  with  an  enema  before  beginning 
the  purgative  course,  as  this  will  give  the  patient  some 
relief  and  leave  less  for  the  purgative  to  do. 

But  it  must  be  remembered  that  merely  flushing  the 
colon  does  not  empty  the  intestinal  canal,  nor  so  cleanse 
the  system  as  to  prevent  reabsorption  of  intestinal  con- 
tents. If  the  system  is  kept  free  from  toxins  of  intestinal 
and  auto-  origin  the  acute  ailment  will  run  practically 
a  normal  course  notwithstanding  the  fact  that  the  patient 
uses  a  narcotic  drug. 


CHAPTER  XVIII. 

REVIEW  OF  LITERATURE. 


DE  QUINCY. 

IN  the  chapter  on  the  history  of  narcotic  addiction 
the  author  expressed  the  opinion  that  the  writings  of 
De  Quincy,  during  the  early  part  of  the  nineteenth  cen- 
tury, did  much  to  call  attention  to  and  to  popularize  the 
use  of  opium. 

The  following  extracts  from  his  writings  on  the 
"Pleasures  of  Opium,"  taken  from  his  "Confessions'  of 
an  English  Opium  Eater,"  are  considered  of  sufficient 
interest  to  justify  their  reproduction  in  this  connec- 
tion : — 

"But,  as  I  do  not  readily  believe  that  any  man,  having  once 
tasted  the  divine  luxuries  of  opium,  will  afterward  descend  to  the 
gross  and  mortal  enjoyment  of  alcohol,  I  take  it  for  granted 

'"That  those  eat  now  who  never  ate  before; 
And  those  who  always  ate,  now  eat  the  more.' 

"Indeed,  the  fascinating  powers  of  opium  are  admitted  even 
by  those  medical  writers  who  are  its  greatest  enemies:  thus,  for 
instance,  Awsiter,  apothecary  to  Greenwich  Hospital,  in  his 
'Essay  on  the  Effects  of  Opium'  (published  in  the  year  1763), 
when  attempting  to  explain  why  Mead  had  not  been  sufficiently 
explicit  on  the  properties,  counteragents,  etc.,  of  this  drug,  ex- 
presses himself  in  the  following  mysterious  terms  (perfectly 
intelligible,  however,  to  those  who  are  in  the  secret)  :  'Perhaps 
he  thought  the  subject  of  too  delicate  a  nature  to  be  made 
common ;  and  as  many  people  might  then  indiscriminately  use  it, 
it  would  take  from  that  necessary  fear  and  caution  which  should 

(347) 


348  Narcotic  Drug  Diseases  and  Allied  Ailments. 

prevent  their  experiencing  the  extensive  power  of  this  drug,  for 
there  are  many  properties  in  it,  if  universally  known,  that  would 
habituate  the  use,  and  make  it  more  in  request  with  us  than  the 
Turks  themselves,  the  result  of  which  knowledge,'  he  adds,  'must 
prove  a  general  misfortune.'  In  the  necessity  of  this  conclusion 
I  do  not  at  all  concur;  but  upon  that  point  I  shall  have  occasion 
to  speak  more  freely  in  the  body  of  the  work  itself.  And  at  this 
point  I  shall  say  no  more  than  that  opium,  as  the  one  sole  catholic 
anodyne  which  hitherto  has  been  revealed  to  man;  secondly,  as 
the  one  sole  anodyne  which  in  a  vast  majority  of  cases  is  irresis- 
tible; thirdly,  as  by  many  degrees  the  most  potent  of  all  known 
counteragents  to  nervous  irritation,  and  to  the  formidable  curse 
of  tedium  vita;  fourthly,  as  by  possibility,  under  an  argument 
undeniably  plausible,  alleged  by  myself,  the  sole  known  agent — 
not  for  curing  when  formed,  but  for  intercepting  whilst  likely  to 
be  formed — the  great  English  scourge  of  pulmonary  consump- 
tion— I  say  that  opium,  as  wearing  these,  or  any  of  these,  four 
beneficent  characteristics — I  say  that  any  agent  whatever  making 
good  such  pretensions,  no  matter  what  its  name — is  entitled 
haughtily  to  refuse  the  ordinary  classification  and  treatment 
which  opium  receives  in  books.  I  say  that  opium,  or  any  agent 
of  equal  power,  is  entitled  to  assume  that  it  was  revealed  to  man 
for  some  higher  object  than  that  it  should  furnish  a  target  for 
moral  denunciations,  ignorant  where  they  are  not  hypocritical, 
childish  where  not  dishonest ;  that  it  should  be  set  up  as  a  theatri- 
cal scarecrow  for  superstitious  terrors,  of  which  the  result  is 
oftentimes  to  defraud  human  suffering  of  its  readiest  alle- 
viations. .  .  . 

"Amongst  the  most  potent  of  anodynes,  we  may  rank  hem- 
lock, henbane,  chloroform,  and  opium.  But  unquestionably  the 
three  first  have  a  most  narrow  field  of  action,  by  comparison  with 
opium.  This,  beyond  all  other  agents  made  known  to  man,  is  the 
mightiest  for  its  command,  and  for  the  extent  of  its  command, 
over  pain;  and  so  much  mightier  than  any  other,  that  I  should 


The  Pleasures  of  Opium.  349 

think,  in  a  Pagan  land,  supposing  it  to  have  been  adequately  made 
known  through  experimental  acquaintance  with  its  revolutionary 
magic,  opium  would  have  had  altars  and  priests  concentrated  to 
its  benign  and  tutelary  powers.  But  this  is  not  my  own  object  in 
the  present  little  work.  Very  many  people  have  thoroughly  mis- 
construed this  object ;  and  therefore  I  beg  to  say  here,  in  closing 
my  original  preface,  a  little  remodelled,  that  what  I  contemplated 
in  these  Confessions  was  to  emblazon  the  power  of  opium — not 
over  bodily  disease  and  pain,  but  over  the  grander  and  more 
shadowy  world  of  dreams.  .  .  . 

"I  have  often  been  asked — how  it  was,  and  through  what 
series  of  steps,  that  I  became  an  opium-eater.  .  .  .  Simply  as 
an  anodyne  it  was,  under  the  mere  coercion  of  pain  the  severest, 
that  I  first  resorted  to  opium;  and  precisely  that  same  torment 
it  is,  or  some  variety  of  that  torment,  which  drives  most  people 
to  make  acquaintance  with  that  same  insidious  remedy.  Such 
was  the  fact;  such  by  accident.  Meantime,  without  blame  it 
might  have  been  otherwise.  If  in  early  days  I  had  fully  under- 
stood the  subtle  powers  lodged  in  this  mighty  drug  (when  judi- 
ciously regulated),  (i)  to  tranquillise  all  irritations  of  the 
nervous  system;  (2)  to  stimulate  the  capacities  of  enjoyment; 
and  (3)  under  any  call  for  extraordinary  exertion  (such  as  all 
men  meet  at  times),  to  sustain  through  twenty-four  consecutive 
hours  the  else-drooping  animal  energies — most  certainly,  know- 
ing or  suspecting  all  this,  I  should  have  inaugurated  my  opium 
career  in  the  character  of  one  seeking  extra  power  and  enjoyment, 
rather  than  of  one  shrinking  from  extra  torment.  And  why  not  ? 
If  that  argued  any  fault,  is  it  not  a  fault  that  most  of  us  commit 
every  day  with  regard  to  alcohol?  Are  we  entitled  to  use  that 
only  as  a  medicine?  Is  wine  unlawful,  except  as  an  anodyne? 
I  hope  not;  else  I  shall  be  obliged  to  counterfeit  and  to  plead 
some  anomalous  tic  in  my  little  finger;  and  thus  gradually,  as  in 
any  Ovidian  metamorphosis,  I,  that  am  at  present  a  truth-loving 
man,  shall  change  by  daily  inches  into  a  dissembler.  No:  the 


350  Narcotic  Drug  Diseases  and  Allied  Ailments. 

whole  race  of  man  proclaim  it  lawful  to  drink  wine  without 
pleading  a  medical  certificate  as  a  qualification.  That  same 
license  extends  itself  therefore  to  the  use  of  opium ;  what  a  man 
may  lawfully  seek  in  wine  surely  he  may  lawfully  find  in  opium; 
and  much  more  so  in  those  cases  (of  which  mine  happens  to  be 
one)  where  opium  deranges  the  animal  economy  less  by  a  great 
deal  than  an  equivalent  quantity  of  alcohol.  Coleridge,  therefore, 
was  doubly  in  error  when  he  allowed  himself  to  aim  most  un- 
friendly blows  at  my  supposed  voluptuousness  in  the  use  of 
opium ;  in  error  as  to  a  principle,  and  in  error  as  to  a  fact.  .  .  . 
Coleridge's  bodily  affliction  was  simple  rheumatism.  Mine, 
which  intermittingly  raged  for  ten  years,  was  rheumatism  in  the 
face  combined  with  toothache.  This  I  had  inherited  from  my 
father;  or  inherited  (I  should  rather  say)  from  my  own  desperate 
ignorance;  since  a  trifling  dose  of  colocynth,  or  of  any  similar 
medicine,  taken  three  times  a  week,  would  more  certainly  than 
opium  have  delivered  me  from  that  terrific  curse.  In  this  igno- 
rance, however,  which  misled  me  into  making  war  upon  toothache 
when  ripened  and  manifesting  itself  in  effects  of  pain,  rather 
than  upon  its  germs  and  gathering  causes,  I  did  but  follow  the 
rest  of  the  world.  To  intercept  the  evil  whilst  yet  in  elementary 
stages  of  formation,  was  the  true  policy;  whereas  I  in  my  blind- 
ness sought  only  for  some  mitigation  to  the  evil  when  already 
formed,  and  past  all  reach  of  interception.  In  this  stage  of  the 
suffering,  formed  and  perfect,  I  was  thrown  passively  upon  chance 
advice,  and  therefore,  by  a  natural  consequence,  upon  opium — 
that  being  the  one  sole  anodyne  that  is  almost  notoriously  such, 
and  which  in  that  great  function  is  universally  appreciated.  .  .  . 
"Any  attentive  reader,  after  a  few  moments'  reflection,  will 
perceive  that,  whatever  may  have  been  the  casual  occasion  of 
mine  or  Coleridge's  opium-eating,  this  could  not  have  been  the 
permanent  ground  of  opium-eating;  because  neither  rheumatism 
nor  toothache  is  any  abiding  affection  of  the  system.  Both  are 
intermitting  maladies,  and  not  at  all  capable  of  accounting  for  a 


The  Pleasures  of  Opium.  351 

permanent  habit  of  opium-eating.  Some  months  are  requisite 
to  found  that.  Making  allowance  for  constitutional  differences,  I 
should  say  that  in  less  than  120  days  no  habit  of  opium-eating 
could  be  formed  strong  enough  to  call  for  any  extraordinary  self- 
conquest  in  renouncing  it,  and  even  suddenly  renouncing  it. 
.  .  .  Rheumatism,  he  says,  drove  him  to  opium.  Very  well, 
but  with  proper  medical  treatment  the  rheumatism  would  soon 
have  ceased ;  or  even,  without  medical  treatment,  under  the  ordi- 
nary oscillations  of  natural  causes.  And  when  the  pain  ceased, 
then  the  opium  should  have  ceased.  Why  did  it  not  ?  Because 
Coleridge  had  come  to  taste  the  genial  pleasure  of  opium,  and 
thus  the  very  impeachment,  which  he  fancied  himself  in  some 
mysterious  way  to  have  evaded,  recoils  upon  him  in  undiminished 
force.  The  rheumatic  attack  would  have  retired  before  the  habit 
could  have  had  time  to  form  itself.  Or  suppose  that  I  underrate 
the  strength  of  the  possible  habit — this  tells  equally  in  my  favour ; 
and  Coleridge  was  not  entitled  to  forget  in  my  case  a  plea  remem- 
bered in  his  own.  It  is  really  memorable  in  the  annals  of  human 
self-deceptions,  that  Coleridge  could  have  held  such  language  in 
the  face  of  such  facts.  I,  boasting  not  at  all  of  my  self-conquests, 
and  owning  no  moral  argument  against  the  free  use  of  opium, 
nevertheless  on  mere  prudential  motives  break  through  the  vassal- 
age more  than  once,  and  by  efforts  which  I  have  recorded  as 
modes  of  transcendent  suffering.  Coleridge,  professing  to  believe 
(without  reason  assigned)  that  opium-eating  is  criminal,  and  in 
some  mysterious  sense  more  criminal  than  wine-drinking  or 
porter-drinking,  having,  therefore,  the  strongest  moral  motive  for 
abstaining  from  it,  yet  suffers  himself  to  fall  into  a  captivity  to 
this  same  wicked  opium,  deadlier  than  was  ever  heard  of,  and 
under  no  coercion  whatever  that  he  has  anywhere  explained  to 
us.  ... 

"But  to  quit  this  episode,  and  to  return  to  my  intercalary  year 
of  happiness.  I  have  said  already  that,  on  a  subject  so  important 
to  us  all  as  happiness,  we  should  listen  with  pleasure  to  any  man's 


352  Narcotic  Drug  Diseases  and  Allied  Ailments. 

experience  or  experiments,  even  though  he  were  but  a  ploughboy, 
who  cannot  be  supposed  to  have  ploughed  very  deep  in  such  an 
intractable  soil  as  that  of  human  pains  and  pleasures,  or  to  have 
conducted  his  researches  upon  any  very  enlightened  principles. 
But,  I,  who  have  taken  happiness,  both  in  a  solid  and  a  liquid 
shape,  both  boiled  and  unboiled,  both  East  Indian  and  Turkish — 
who  have  conducted  my  experiments  upon  this  interesting  subject 
with  a  sort  of  galvanic  battery,  and  have,  for  the  general  benefit 
of  the  world,  inoculated  myself,  as  it  were,  with  the  poison  of 
eight  thousand  drops  of  laudanum  per  day  (and  for  the  same 
reason  as  a  French  surgeon  inoculated  himself  lately  with  a 
cancer,  an  English  one,  twenty  years  ago,  with  plague,  and  a  third, 
who  was  also  English,  with  hydrophobia),  I,  it  will  be  admitted, 
must  surely  now  know  what  happiness  is,  if  anybody  does.  And 
therefore  I  will  here  lay  down  an  analysis  of  happiness ;  and,  as 
the  most  interesting  mode  of  communicating  it,  I  will  give  it,  not 
didactically,  but  wrapped  up  and  involved  in  a  picture  of  one 
evening,  as  I  spent  every  evening  during  the  intercalary  year, 
when  laudanum,  though  taken  daily,  was  to  me  no  more  than  the 
elixir  of  pleasure." 

A  number  of  articles  descriptive  of  the  pleasures  of 
opium  appeared  in  the  London  Magazine,  beginning  as 
early  as  the  year  1821,  and  these  continued  to  appear 
from  time  to  time  for  a  number  of  years.  These  articles 
attracted  much  attention.  An  editorial  note  called 
special  attention  to  the  first  of  these,  and  upon  the 
appearance  of  the  second  this  was  repeated  with  em- 
phasis, with  a  special  tribute  to  "the  deep,  eloquent, 
and  masterly  paper  which  stands  first  in  our  present 
number." 

It  can  readily  be  seen  that  such  articles  appearing  in 
the  leading  magazines  of  the  times  would  lead  many 
to  experiment  with  a  drug  possessing  the  wonderful 


Difficulties  in  Renouncing.  353 

powers  attributed  by  the  writer  to  this  one.  These 
experiments  led  many  to  hopeless  slavery  before  the 
later  writings  of  De  Quincy  appeared  to  give  them 
warning  of  their  danger.  It  was  not  until  a  number  of 
years  later  that  he  realized  the  abject  slavery  growing 
out  of  the  habitual  use  of  opium  and  then  his  writings 
changed  in  their  character  and  from  that  time  on  he 
wrote  on  the  "Pains  of  Opium,"  but  his  writings  on  the 
"Pains"  were  not  so  popular  and  did  not  attract  any- 
thing like  the  attention  that  the  writings  on  the 
"Pleasures"  had  done,  and  the  later  writings  were  not 
able  to  "catch  up"  with  the  earlier  writings  or  to  any- 
thing like  offset  the  damage  done  by  them.  He  used 
opium  for  over  fifty  years,  in  the  form  of  gum  opium 
at  first  and  later  in  the  form  of  laudanum. 

The  following  extracts  are  examples  of  his  later  writings : — 
"The  fact  is,  I  imagine  myself  writing  at  a  distance  of  twenty 
— thirty — fifty  years  ahead  of  this  present  moment,  either  for  the 
satisfaction  of  the  few  who  may  then  retain  any  interest  in 
myself,  or  of  the  many  (a  number  that  is  sure  to  be  continually 
growing)  who  will  take  an  inextinguishable  interest  in  the 
mysterious  powers  of  opium.  For  opium  is  mysterious ;  mysteri- 
ous to  the  extent,  at  times,  of  apparent  self-contradiction;  and 
so  mysterious,  that  my  own  long  experience  in  its  use — sometimes 
even  in  its  abuse — did  but  mislead  me  into  conclusions  ever  more 
and  more  remote  from  what  I  now  suppose  to  be  the  truth. 
Fifty-and-two  years'  experience  of  opium,  as  a  magical  resource 
under  all  modes  of  bodily  suffering,  I  may  now  claim  to  have 
had — allowing  only  for  some  periods  of  four  and  six  months, 
during  which,  by  unexampled  efforts  of  self -conquest,  I  had 
accomplished  a  determined  abstinence  from  opium.  These 
parentheses  being  subtracted,  as  also,  and  secondly,  some  off-and- 
on  fits  of  tentative  and  intermitting  dalliance  with  opium  in  the 


23 


354  Narcotic  Drug  Diseases  and  Allied  Ailments. 

opening  of  my  career — these  deductions  allowed  for,  I  may 
describe  myself  as  experimentally  acquainted  with  opium  for 
something  more  than  half-a-century.  What,  then,  is  my  final 
report  upon  its  good  and  evil  results?  .  .  . 

"But  now  farewell,  a  long  farewell,  to  happiness,  winter  or 
summer!  farewell  to  smiles  and  laughter!  farewell  to  peace  of 
mind,  to  tranquil  dreams,  and  to  the  blessed  consolations  of  sleep ! 
For  more  than  three  years  and  a  half  I  am  summoned  away  from 
these.  Here  opens  upon  me  an  Iliad  of  woes;  for  I  now  enter 
upon  the  pains  of  opium" 

Copy  from  De  Quincy's  Confessions, 
Pages  106  to  109. 

"THE  PAINS  OF  OPIUM. 

"At  length  a  friend  in  Edinburgh  sent  me  down  Mr.  Ricardo's 
book;  and,  recurring  to  my  own  prophetic  anticipation  of  the 
advent  of  some  legislator  for  this  science,  I  said,  before  I  had 
finished  the  first  chapter,  'Thou  art  the  man.'  Wonder  and 
curiosity  were  emotions  that  had  long  been  dead  in  me.  Yet  I 
wondered  once  more:  I  wondered  at  myself  that  I  could  once 
again  be  stimulated  to  the  effort  of  reading;  and  much  more  I 
wondered  at  the  book.  Had  this  profound  work  been  really 
written  in  England  during  the  nineteenth  century?  Was  it  pos- 
sible? I  supposed  thinking  had  been  extinct  in  England.  Could 
it  be  that  an  Englishman,  and  he  not  in  academic  bowers,  but 
oppressed  by  mercantile  and  senatorial  cares,  had  accomplished 
what  all  the  universities  of  Europe,  and  a  century  of  thought, 
had  failed  even  to  advance  by  one  hair's  breath?  All  other 
writers  had  been  crushed  and  overlaid  by  the  enormous  weight 
of  facts  and  documents ;  Mr.  Ricardo  had  deduced,  a  priori,  from 
the  understanding  itself,  laws  which  first  gave  a  ray  of  light  into 
unwieldy  chaos  of  materials,  and  had  constructed  what  had  been 
but  a  collection  of  tentative  discussions  into  a  science  of  regular 
proportions,  now  first  standing  on  an  eternal  basis. 


The  Pains  of  Opium.  355 

"Thus  did  one  simple  work  of  profound  understanding  avail 
to  give  me  a  pleasure  and  an  activity  which  I  had  not  known  for 
years :  it  roused  me  even  to  write,  or,  at  least,  to  dictate  what 
M.  wrote  for  me.  It  seemed  to  me  that  some  important  truths 
had  escaped  even  'the  inevitable  eye'  of  Mr.  Ricardo;  and,  as 
these  were,  for  the  most  part,  of  such  a  nature  that  I  could 
express  or  illustrate  them  more  briefly  and  elegantly  by  algebraic 
symbols  than  in  the  usual  clumsy  and  loitering  diction  of  econo- 
mists, the  whole  would  not  have  filled  a  pocket-book;  and  being 
so  brief,  with  M.  for  my  amanuensis,  even  at  this  time,  incapable 
as  I  was  of  all  general  exertion,  I  drew  up  my  prolegomena  to  all 
future  systems  of  political  economy.  I  hope  it  will  not  be  found 
redolent  of  opium,  though  indeed,  to  most  people,  the  subject 
itself  is  a  sufficient  opiate. 

"This  exertion,  however,  was  but  a  temporary  flash,  as  the 
sequel  showed,  for  I  designed  to  publish  my  work.  Arrange- 
ments were  made  at  a  provincial  press,  about  eighteen  miles 
distant,  for  printing  it.  An  additional  compositor  was  retained 
for  some  days  on  this  account.  The  work  was  even  twice  adver- 
tised ;  and  I  was,  in  a  manner,  pledged  to  the  fulfillment  of  my 
intention.  But  I  had  a  preface  to  write ;  and  a  dedication,  which 
I  wished  to  make  a  splendid  one  to  Mr.  Ricardo.  I  found  myself 
quite  unable  to  accomplish  all  this.  The  arrangements  were 
countermanded,  the  compositor  dismissed,  and  my  'prolegomena' 
rested  peacefully  by  the  side  of  its  elder  and  more  dignified 
brother. 

"I  have  thus  described  and  illustrated  my  intellectual  torpor, 
in  terms  that  apply,  more  or  less,  to  every  part  of  the  four  years 
during  which  I  was  under  the  Circean  spells  of  opium.  But  for 
misery  and  suffering,  I  might,  indeed,  be  said  to  have  existed  in 
a  dormant  state.  I  seldom  could  prevail  on  myself  to  write  a 
letter ;  an  answer  of  a  few  words,  to  any  that  I  received,  was  the 
utmost  that  I  could  accomplish,  and  often  that  not  until  the  letter 
had  lain  weeks,  or  even  months,  on  my  writing-table.  Without 


356  Narcotic  Drug  Diseases  and  Allied  Ailments. 

the  aid  of  M.,  all  records  of  bills  paid,  or  to  be  paid,  must  have 
perished;  and  my  whole  domestic  economy,  whatever  became  of 
political  economy,  must  have  gone  into  irretrievable  confusion.  I 
shall  not  afterward  allude  to  this  part  of  the  case ;  it  is  one,  how- 
ever, which  the  opium-eater  will  find,  in  the  end,  as  oppressive 
and  tormenting  as  any  other,  from  the  sense  of  incapacity  and 
feebleness,  from  the  direct  embarrassment  incident  to  the  neglect 
or  procrastination  of  each  day's  appropriate  duties,  and  from  the 
remorse  which  must  often  exasperate  the  stings  of  these  evils  to 
a  reflective  and  conscientious  mind.  The  opium-eater  loses  none 
of  his  moral  sensibilities  or  aspirations;  he  wishes  and  longs  as 
earnestly  as  ever  to  realize  what  he  believes  possible,  and  feels 
to  be  exacted  by  duty;  but  his  intellectual  apprehension  of  what 
is  possible  infinitely  outruns  his  power,  not  of  execution  only,  but 
of  even  power  to  attempt.  He  lies  under  the  weight  of  incubus 
and  nightmare ;  he  lies  in  sight  of  all  that  he  would  fain  perform, 
just  as  a  man  forcibly  confined  to  his  bed  by  the  mortal  languor 
of  a  relaxing  disease,  who  is  compelled  to  witness  injury  or  out- 
rage offered  to  some  object  of  his  tenderest  love;  he  curses  the 
spells  which  chain  him  down  from  motion,  he  would  lay  down  his 
life  if  he  might  get  up  and  walk,  but  he  is  powerless  as  an  infant, 
and  cannot  even  attempt  to  rise.  .  .  . 

"However,  as  some  people,  in  spite  of  all  laws  to  the  con- 
trary, will  persist  in  asking  what  became  of  the  opium-eater,  and 
in  what  state  he  now  is,  I  answer  for  him  thus:  The  reader  is 
aware  that  opium  had  long  ceased  to  found  its  empire  on  spells  of 
pleasure ;  it  was  solely  by  the  tortures  connected  with  the  attempt 
to  abjure  it,  that  it  kept  its  hold.  Yet,  as  other  tortures,  no  less, 
it  may  be  thought,  attended  the  non-abjuration  of  such  a  tyrant, 
a  choice  only  of  evils  was  left ;  and  that  might  as  well  have  been 
adopted,  which,  however  terrific  in  itself,  held  out  a  prospect  of 
final  restoration  to  happiness.  This  appears  true ;  but  good  logic 
gave  the  author  no  strength  to  act  upon  it.  However,  a  crisis 
arrived  for  the  author's  life,  and  a  crisis  for  other  objects  still 


The  Pains  of  Opium.  357 

dearer  to  him,  and  which  will  always  be  far  dearer  to  him  than 
life,  even  now  that  it  is  again  a  happy  one.  I  saw  that  I  must 
die,  if  I  continued  the  opium:  I  determined,  therefore,  if  that 
should  be  required,  to  die  in  throwing  it  off.  How  much  I  was 
at  that  time  taking,  I  cannot  say ;  for  the  opium  which  I  used  had 
been  purchased  for  me  by  a  friend,  who  afterward  refused  to 
let  me  pay  him ;  so  that  I  could  not  ascertain  even  what  quantity 
I  had  used  within  a  year.  I  apprehend,  however,  that  I  took  it 
very  irregularly,  and  that  I  varied  from  about  50  or  60  grains  to 
150  a  day.  My  first  task  was  to  reduce  it  to  40,  to  30,  and,  as  fast 
as  I  could,  to  12  grains. 

"I  triumphed ;  but  think  not,  reader,  that  therefore  my  suffer- 
ings were  ended;  nor  think  of  me  as  of  one  sitting  in  a  dejected 
state.  Think  of  me  as  of  one,  even  when  four  months  had 
passed,  still  agitated,  writhing,  throbbing,  palpitating,  shattered; 
and  much,  perhaps,  in  the  situation  of  him  who  has  been  racked, 
as  I  collect  the  torments  of  that  state  from  the  affecting  account 
of  them  left  by  the  most  innocent  sufferer  (of  the  time  of  James 
I).  Meantime,  I  derived  no  benefit  from  any  medicine,  except 
one  prescribed  to  me  by  an  Edinburgh  surgeon  of  great  eminence, 
namely,  ammoniated  tincture  of  valerian.  Medical  account,  there- 
fore, of  my  emancipation,  I  have  not  much  to  give ;  and  even  that 
little,  as  managed  by  a  man  so  ignorant  of  medicine  as  myself, 
would  be  misplaced  in  this  situation.  The  moral  of  the  narrative 
is  addressed  to  the  opium-eater;  and  therefore,  of  necessity, 
limited  in  its  application.  If  he  is  taught  to  fear  and  tremble, 
enough  has  been  effected.  But  he  may  say,  that  the  issue  of  my 
case  is  at  least  a  proof  that  opium,  after  a  seventeen  years'  use, 
and  an  eight  years'  abuse  of  its  powers  may  still  be  renounced; 
and  that  he  may  chance  to  bring  to  the  task  greater  energy  than 
I  did,  or  that  with  a  stronger  constitution  than  mine,  he  may 
obtain  the  same  results  with  less.  This  may  be  true;  I  would  not 
presume  to  measure  other  men  by  my  own.  I  heartily  wish  him 
more  energy,  I  wish  him  the  same  success.  Nevertheless,  I  had 


358  Narcotic  Drug  Diseases  and  'Allied  Ailments. 

motives  external  to  myself  which  he  may  unfortunately  want; 
and  these  supplied  me  with  conscientious  support,  which  mere 
personal  interest  might  fail  to  supply  to  a  mind  debilitated  by 
opium. 

"Jeremy  Taylor  conjectures  that  it  may  be  as  painful  to  be 
born  as  to  die.  I  think  it  probable ;  and,  during  the  whole  period 
of  diminishing  the  opium,  I  had  the  torments  of  a  man  passing 
out  of  one  mode  of  existence  into  another.  The  issue  was  not 
death,  but  a  sort  of  physical  regeneration,  and,  I  may  add,  that 
ever  since,  at  intervals,  I  have  had  a  restoration  of  more  than 
youthful  spirits,  though  under  the  pressure  of  difficulties,  which, 
in  a  less  happy  state  of  mind,  I  should  have  called  mis- 
fortunes. 

"Opium,  therefore,  I  resolved  wholly  to  abjure,  as  soon  as 
I  should  find  myself  at  liberty  to  bend  my  undivided  attention 
and  energy  to  this  purpose.  It  was  not,  however,  until  the  24th 
of  June  last  that  any  tolerable  concurrence  of  facilities  for  such 
an  attempt  arrived.  On  that  day  I  began  my  experiment,  having 
previously  settled  in  my  own  mind  that  I  would  not  flinch,  but 
would  'stand  up  to  the  scratch,'  under  any  possible  'punishment.' 
I  must  premise,  that  about  170  or  180  drops  had  been  my  ordinary 
allowance  for  many  months.  Occasionally  I  had  run  up  as  high 
as  500,  and  once  nearly  to  700.  In  repeated  preludes  to  my  final 
experiment  I  had  also  gone  as  low  as  100  drops,  but  had  found 
it  impossible  to  stand  it  beyond  the  fourth  day,  which,  by  the 
way,  I  have  always  found  more  difficult  to  get  over  than  any  of 
the  preceding  three.  I  went  off  under  easy  sail — 130  drops  a  day 
for  three  days;  on  the  fourth  I  plunged  at  once  to  80.  The 
misery  which  I  now  suffered  'took  the  conceit'  out  of  me  at  once ; 
and  for  about  a  month  I  continued  off  and  on  about  this  mark ; 
then  I  sunk  to  60,  and  the  next  day  to — none  at  all.  This  is  the 
first  day  for  nearly  ten  years  that  I  had  existed  without  opium. 
I  persevered  in  my  abstinence  for  ninety  hours ;  that  is,  upwards 
of  half  a  week.  Then  I  took — ask  me  not  how  much;  say,  ye 


An  Heroic  Effort  to  Renounce.  359 

severest,  what  would  ye  have  done?  Then  I  abstained  again ;  then 
took  about  twenty-five  drops ;  then  abstained ;  and  so  on. 

"Meantime,  the  symptoms  which  attended  my  case  for  the 
first  six  weeks  of  the  experiment  were  these :  enormous  irritability 
and  excitement  of  the  whole  system;  the  stomach,  in  particular, 
restored  to  a  full  feeling  of  vitality  and  sensibility,  but  often 
in  great  pain;  unceasing  restlessness  night  and  day;  sleep — I 
scarcely  knew  what  it  was — three  hours  out  of  the  twenty-four 
was  the  utmost  I  had,  and  that  so  agitated  and  shallow  that  I 
heard  every  sound  that  was  near  me;  lower  jaw  constantly 
swelling ;  mouth  ulcerated ;  and  many  other  distressing  symptoms 
that  would  be  tedious  to  repeat,  amongst  which,  however,  I  must 
mention  one,  because  it  had  never  failed  to  accompany  any  at- 
tempt to  renounce  opium, — namely,  violent  sternutation  (sneez- 
ing). This  now  became  exceedingly  troublesome;  sometimes 
lasting  for  two  hours  at  once,  and  recurring  at  least  twice  or 
three  times  a  day.  I  was  not  much  surprised  at  this,  on  recollect- 
ing what  I  had  somewhere  heard  or  read,  that  the  membrane 
which  lines  the  nostrils  is  a  prolongation  of  that  which  lines  the 
stomach;  whence,  I  believe,  are  explained  the  inflammatory 
appearances  about  the  nostrils  of  the  dram-drinker.  The  sudden 
restoration  of  its  original  sensibility  to  the  stomach  expressed 
itself,  I  suppose,  in  this  way.  It  is  remarkable,  also,  that,  during 
the  whole  period  of  years  through  which  I  had  taken  opium,  I 
had  never  once  caught  cold  (as  the  phrase  is),  nor  even  had  the 
slightest  cough.  But  now  a  violent  cold  attacked  me,  and  a 
cough  soon  after.  In  an  unfinished  fragment  of  a  letter  begun 

about  this  time  to I  find  these  words :    'You  ask  me  to  write 

the  .  .  .  Do  you  know  Beaumont  and  Fletcher's  play  of 
Thuerry  and  Theodoret?'  There  you  will  see  my  case  as  to 
sleep;  nor  is  it  much  of  an  exaggeration  in  other  features.  I 
protest  to  you  that  I  have  a  greater  influx  of  thoughts  in  one 
hour  at  present  than  in  a  whole  year  under  the  reign  of  opium. 
It  seems  as  though  all  the  thoughts  which  had  been  frozen  up  for 


360  Narcotic  Drug  Diseases  and  Allied  Ailments. 

a  decade  of  years  by  opium  had  now,  according  to  the  old  fable, 
been  thawed  at  once,  such  a  multitude  stream  in  upon  me  from 
all  quarters.  Yet  such  is  my  impatience  and  hideous  irritability, 
that,  for  one  which  I  detain  and  write  down,  fifty  escape  me. 
In  spite  of  my  weariness  from  suffering  and  want  of  sleep,  I 
cannot  stand  still  or  sit  for  two  minutes  together. 

"  'I  munc,  et  versus  tecum  meditare  canorus.' 

"By  the  advice  of  the  surgeon,  I  tried  bitters.  For  a  short 
time  these  greatly  mitigated  the  feelings  under  which  I  labored ; 
but  about  the  forty-second  day  of  the  experiment  the  symptoms 
already  noticed  began  to  retire,  and  new  ones  to  arise  of  a  differ- 
ent and  far  more  tormenting  class.  Under  these,  with  but  a  few 
intervals  of  remission,  I  have  since  continued  to  suffer." 

AUTHOR'S  COMMENT. 

The  author  wishes  to  emphasize  the  last  paragraph 
in  the  foregoing  extract  from  De  Quincy's  writings.  A 
resort  to  alcoholic  drinks  of  any  kind  is  one  of  the  most 
dangerous  things  an  ex-habitue  can  do.  The  demand 
for  the  effects  of  alcohol  grows  upon  such  a  person  so 
rapidly  that  self-control  is  very  quickly  lost  and  then 
every  step  forward  is  more  distressing.  There  is  no 
escape,  so  far  as  the  victim's  own  efforts  go,  except 
through  a  return  to  the  opiate  and  that  is  like  "jumping 
out  of  the  frying  pan  into  the  fire." 

It  is  suggested  to  physicians  and  others  who  are 
so  ready  with  advice  to  drug  users  to  quit  taking  their 
drug,  "just  to  quit,"  that  a  careful  study  of  De  Quincy's 
experience  in  "quitting"  might  give  them  different  ideas 
from  those  now  held  as  to  the  ease  with  which  "quitting" 
can  be  done.  His  persistent,  heroic  efforts  for  freedom 
were  almost  superhuman  and  yet  they  were  not  rewarded 
with  success.  It  would  seem  hardly  worth  while  for 


Danger  of  Engrafting  Alcohol.  361 

others  to  undertake  to  do  in  this  line  what  a  methodical, 
stoical  Englishman  could  not  do,  and  yet  the  advice  "just 
quit  it"  is  ready  on  every  hand. 

Quitting  opium  by  sheer  force  of  will  is  a  thing  to  be 
dreamed  of,  but  hardly  to  be  accomplished. 


CHAPTER  XIX. 

REVIEW  OF  LITERATURE   (CONTINUED). 


ERLENMEYER. 

"THE  treatment  of  the  morphine  habit  is  threefold;  First, 
the  use  of  the  poison  must  be  discontinued ;  second,  the  physical 
and  mental  disturbances  arising  during  the  period  of  the  with- 
drawal must  be  combated;  and  third,  after  the  patient  is  cured, 
means  must  be  taken  to  prevent  a  return  to  the  habit. 

"Before  taking  up  these  points  seriatim,  a  few  words  about 
the  general  principles  of  treatment  seem  necessary. 

"During  the  entire  period  of  abstinence,  the  craving  for 
morphine  enters  as  a  very  important  element,  and  in  consequence 
of  this  craving,  the  patient  is  frequently  utterly  uncontrollable. 
Then,  when  the  habit  is  partially  overcome,  the  danger  of  a 
relapse  is  always  to  be  borne  in  mind  and  provided  against.  .  .  . 

"Methods  of  Withdrawal. — There  are  three  methods  of 
withdrawal : — 

"i.  The  gradual  mode. 

"2.  The  sudden  mode. 

"3.  The  rapid  mode. 

"i.  THE  GRADUAL  MODE. 

"This  is  the  oldest  of  the  various  methods  of  discontinuance ; 
the  first  in  vogue,  and  till  recently,  practised  by  almost  all  physi- 
cians in  the  treatment  of  morphiomania.  I  myself  formerly 
depended  on  this  method,  but  being  convinced  of  its  unsatisfactory 
character,  some  years  ago  I  abandoned  it  for  what  has  proved  to 
be  a  more  rational  system.  The  nature  of  this  mode  of  treatment 
is  indicated  by  its  name.  It  is  the  'tapering-off  method  of  the 
English.  The  daily  dose  of  morphine  is  decreased  by  a  very 
(362) 


Gradual  Reduction  Condemned.  363 

small  fraction,  then  the  drug  is  finally  left  off  altogether.  The 
amount  of  decrease  each  day  is  made  dependent  on  the  appearance 
or  absence  of  certain  symptoms  known  as  phenomena  of  absti- 
nence. The  more  pronounced  these  symptoms  and  the  greater 
their  severity,  the  smaller  must  be  the  reduction  of  the 
opiate.  .  .  . 

"A  second  equally  great  disadvantage  of  this  method  is  the 
prolongation  of  the  morbid  phenomena  which  characterize  the 
abstinence  period ;  the  patient  is  kept  in  misery,  and  loses  strength 
and  flesh. 

"I  cannot  agree  with  those  who  affirm  that  the  patient  can 
better  endure  the  abstinence  symptoms  under  the  slow  than  under 
the  sudden  method.  The  symptoms  might  be  less  severe  for  a 
single  day,  but  surely  the  sum  of  discomfort  will  be  greater 
during  the  slow  process  of  leaving  off  than  during  the  quicker 
processes.  A  gradual  treatment  drags  along  three  or  four  or 
even  more  weeks;  the  patient  cannot  recuperate,  and  convales- 
cence is  very  tedious.  The  affirmation  which  has  been  made 
against  the  quick  and  in  favor  of  the  gradual  process — that  the 
organism  can  better  endure  lesser  and  more  prolonged  perturba- 
tions and  strains  than  stronger  and  more  rapid — contradicts  ex- 
perience in  all  departments  of  pathology.  I  must  call  your  atten- 
tion to  the  fact  that  the  patient  during  the  carrying  out  of  the 
gradual  method  of  treatment  is  not  spared  a  single  symptom 
peculiar  to  the  sudden  method  excepting  perhaps  the  collapse, 
for  what  he  gains  in  the  lesser  intensity  of  the  symptoms,  he 
loses  in  the  longer  duration.  .  .  . 

"No  benefits  are  derived  by  the  patient  from  this  method; 
the  only  benefits  are  realized  by  the  physician  and  his  institute. 

"Therefore  I  do  not  hesitate  to  declare  that  this  slow  method 
is  wholly  unreliable  and  unsatisfactory.  I  have  had  ten  years' 
experience  with  it  in  our  institution,  only  to  be  more  and  more 
convinced  of  its  worthlessness.  .  .  . 


364  Narcotic  Drug  Diseases  and  Allied  Ailments. 

"2.  THE  SUDDEN  METHOD  OF  WITHDRAWAL. 

"Levinstein  was  the  first  exponent  and  defender  of  this 
method,  which  is  now  called  the  Levinstein  method. 

"The  principle  of  this  method  consists  in  the  patient  being 
at  once  wholly  deprived  of  the  use  of  morphine.  When  he 
enters  the  institute,  his  supply  is  stopped,  and  he  is  kept  under 
constant  surveillance  so  that  he  can  obtain  no  more.  He  is 
generally  put  to  bed,  and  kept  there  a  while.  .  .  . 

"The  delirium  maniacale,  one  of  the  first  symptoms  of  the 
sudden  withdrawal,  which  is  always  connected  with  certain 
dangers  to  the  attendant,  cannot,  of  course,  be  treated  in  every 
place,  and  by  everybody.  In  order  that  this  period  of  high  excite- 
ment may  pass  safely,  certain  precautions  and  means  for  security 
of  persons  and  property  are  necessary.  Above  all,  it  is  important 
that  the  part  of  the  hospital  where  the  patient  is  treated  shall  be 
separated  from  all  other  apartments  and  wards.  Not  only  must 
the  patient  be  isolated  in  order  to  prevent  any  possible  obtention 
of  drugs,  but  the  other  patients  must  not  be  disturbed  by  the 
maniacal  cries  and  noise  of  the  morphine  victim.  The  room  in 
which  the  latter  is  undergoing  treatment  must  contain  no  movable 
furniture,  or  any  utensils  that  can  be  broken.  A  strong  bedstead, 
a  night-chair,  and  a  common  chair  or  lounge  are  all  that  is  re- 
quired. All  kinds  of  smaller  furniture  and  vessels  are  strictly 
to  be  removed  out  of  the  way,  as  they  may  become  dangerous 
weapons  in  the  hands  of  the  excited  patient;  especially  must 
knives,  scissors,  etc.,  be  kept  away.  The  doors  are  to  be  securely 
locked,  and  the  windows  are  to  be  so  arranged  that  no  danger 
whatever  can  be  feared.  Heating  and  lighting  arrangements 
require  great  care.  It  is  recommended  to  have  an  adjacent  room 
free,  for  meals  or  entertainment  of  company,  where  the  patient 
may  spend  quiet  hours,  and  where  also  may  be  kept  on  hand  the 
necessary  remedies  for  certain  symptoms  as  they  may  arise: 
wine  and  brandy,  and  ether;  also  ice- water,  etc.  Cooking  appli- 


Erlenmeyer's  Rapid  Method.  365 

ances  should  also  be  conveniently  at  hand,  and  a  bathroom  should 
be  readily  accessible. 

"The  assistants  and  servants  must  be  persons  on  whom  for 
conscientiousness  and  fidelity  you  can  rely ;  the  subordinate  medi- 
cal attendants  and  the  nurses  must  not  be  susceptible  to  persuasion 
or  to  bribery,  so  that  all  possibility  of  obtention  of  morphine  shall 
be  out  of  the  question.  The  physician-in-chief  or  his  subordinates 
must  be  with  the  patient  night  and  day  during  the  first  few  days 
of  the  treatment,  when  the  struggle  is  greatest;  there  will  be  a 
collapse  of  the  vital  forces,  and  it  may  be  a  matter  of  life  or 
death  for  the  patient,  and  in  this  hour  of  danger,  ripe  experience, 
presence  of  mind,  and  readiness  in  emergencies  are  necessary  in 
physicians  and  attendants.  They  must  pitilessly  resist  the  impor- 
tunities of  the  patient  for  morphine,  while,  at  the  same  time, 
they  must  not  lose  their  compassion  and  sympathy  for  the  poor 
sufferer.  There  will  be  numerous  symptoms  constantly  occurring, 
such  as  vomiting,  diarrhea,  restlessness,  which  will  demand  atten- 
tion and  will  keep  the  medical  attendant  and  nurses  busy;  there 
will  for  a  time,  in  fact,  be  no  rest  for  anybody.  The  responsibility 
of  keeping  the  patient  from  inflicting  injury  on  himself  is  no 
light  strain  on  the  nerves  of  the  physician,  who  must  exercise 
untiring  vigilance,  and  no  one  can  endure  this  strain  more  than 
twelve  hours  without  respite  and  rest.  In  fact,  the  severity  of 
the  task  renders  frequent  change  with  fresh  attendants  necessary, 
and  an  institution  which  attempts  to  carry  out  this  method  of 
cure  is  obliged  to  keep  on  hand  a  large  cortege  of  assistants  and 
nurses.  .  .  . 

"3.  THE  RAPID  METHOD  OF  WITHDRAWAL. 

"A  modified  method  of  discontinuance  had  already  been 
employed  by  Levinstein,  though  only  in  severe  cases  of  disease  or 
weakness  where  it  would  be  dangerous  to  apply  the  sudden 
method,  as  in  phthisis,  emphysema,  heart  disease,  etc.,  and  in  the 
case  of  very  sensitive  persons,  especially  women. 


366  Narcotic  Drug  Diseases  and  Allied  Ailments. 

"In  my  endeavors  to  find  and  develop  a  method  which  would 
be  only  of  benefit  and  could  never  be  an  injury  or  disadvantage  to 
the  patient,  I  began  with  this  modified  system;  I  have  further 
improved  upon  it,  and  now  rely  upon  it  almost  exclusively. 
Formerly  I  called  it  the  modified  slow  method;  1  now  call  it  the 
rapid  mode. 

"My  method  has  really  nothing  in  common  with  Levinstein's 
modified  mode  of  withdrawal.  By  the  latter  process,  the  patient 
without  regard  to  the  doses  which  he  had  previously  been  taking, 
is  at  once,  for  the  first  two  or  three  days  of  his  treatment,  put  on 
the  short  allowance  of  5  centigrammes  (about  a  grain)  of  mor- 
phine. This  virtually  amounts  to  the  sudden  method  of  with- 
drawal of  which  I  have  before  spoken,  and  takes  no  account  of 
accustomed  doses,  the  duration  of  the  habit,  and  the  condition  of 
the  patient;  it  is,  in  fact,  applied  to  every  case  whose  treatment 
seems  to  require  modification  in  consideration  of  the  circum- 
stances above  mentioned. 

"The  nature  of  the  method  which  I  now  advocate  consists  in 
as  rapidly  as  possible  removing  the  morphine,  though  not 
suddenly,  the  aim  being  to  avoid  any  danger  of  death.  My  experi- 
ence has  taught  me  that  from  six  to  twelve  days  are  sufficient  to 
accomplish  the  weaning,  although  the  time  required  for  a  cure 
depends  largely  upon  the  quantity  of  morphine  which  the  patient 
has  been  in  the  habit  of  taking,  the  duration  of  his  bondage  to 
the  habit,  and  the  number  and  kinds  of  'cures'  which  he  has 
already  passed  through,  which  make  each  following  treatment 
more  difficult;  lastly,  on  the  age  and  physical  constitution  of  the 
patient.  During  the  first  two  to  six  days,  I  endeavor  to  with- 
draw altogether  habitual  doses  of  from  30  to  60  centigrammes  (5 
to  8  grains),  and  find  that  ten  days  are  sufficient,  without  collapse 
ensuing,  or  disturbances  in  the  breathing  or  pulse,  for  the  with- 
drawal of  daily  doses  amounting  to  1.5  to  2  grammes  of  mor- 
phine. .  .  . 


Symptomatic  Treatment.  367 

SYMPTOM -TREAT  ME  NT  DIRECTED  TO  THE  CONSEQUENCES 
OF  ABSTINENCE. 

"The  symptoms  occurring  during  the  treatment  are  the  conse- 
quences of  the  discontinuance  of  a  powerful  drug  to  which  the 
organism  has  become  accustomed.  They  constitute  the  reaction, 
which  occurs  to  a  greater  or  less  extent  no  matter  what  method 
of  leaving  off  is  employed.  The  disappearance  of  these  symptoms 
is  only  a  question  of  time,  but  while  they  last,  what  can  be  done 
must  be  done  to  mitigate  their  severity.  We  will  consider  in 
their  order  the  various  phenomena  rendering  a  symptomatic 
therapy  necessary. 

"THE  COLLAPSE. 

"This  is  the  most  dangerous  of  all  symptoms  resulting  from 
the  withdrawal.  It  demands  a  prompt  and  energetic  treatment 
from  the  danger  to  life  which  attends  it.  It  must  not  be  forgotten 
that  a  case  of  collapse  apparently  very  light  may  become  severe 
and  even  fatal;  therefore,  this  symptom  must  be  early  and 
effectively  met.  Fortunately,  there  is  always  at  hand  a  sovereign 
remedy  which,  taken  at  the  proper  time,  will  obviate  all  the 
danger  of  the  collapse ;  I  refer  to  morphine. 

"As  soon  as  the  first  symptoms:  irregularity  of  the  pulse 
and  respiration,  pallor  and  lividity  of  the  skin  and  mucous  mem- 
branes, feelings  of  faintness,  make  their  appearance,  an  injection 
of  0.025  (%  grain)  of  morphine  is  made.  If  after  ten  or  twelve 
minutes  the  symptoms  do  not  subside,  or  if  others  should  develop, 
the  same  injection  is  repeated,  and  this  may  be  done  three  or  four 
times  in  succession.  Other  means,  such  as  ether  injections,  are 
uncertain  and  unreliable.  I  repeat,  you  must  not  hesitate  to 
resort  to  the  morphine  injections  on  the  least  appearance  of  col- 
lapse. There  is,  moreover,  a  series  of  analeptic  medicines  to  be 
employed  as  adjuvants,  viz.,  hot  tea  or  coffee,  alcoholic  stimulants, 
as  Cognac,  port  wine,  or  champagne,  besides  cutaneous  irritation, 
hot-water  applications  over  the  abdomen,  etc. 


368  Narcotic  Drug  Diseases  and  Allied  Ailments. 

"In  case  the  respiration  should  stop,  faradization  of  the 
phrenic  nerves  should  be  attempted.  When  the  danger  has 
passed,  the  pulse  and  respiration  are  still  to  be  watched  for  some 
time,  especially  during  the  sleep  which  usually  follows  the  collapse. 
The  severer  symptoms,  however,  do  not  all  make  their  appear- 
ance if  the  morphine  is  injected  early. 

"DELIRIUM. 

"The  milder  forms  of  delirium  that  appear  during  the  slow 
method  of  withdrawal  generally  pass  off  with  the  use  of  alcoholic 
stimulants.  For  the  maniacal  delirium,  however,  two  or  three 
morphine  injections  may  be  required,  especially  when  the  excite- 
ment assumes  a  dangerous  aspect.  Apart  from  this,  the  thera- 
peutics of  delirium  tremens,  such  as  large  doses  of  chloral, 
paraldehyde,  or  opium,  are  also  here  applicable.  .  .  . 

"DIARRHEA  AND  COLIC. 

"The  first  of  these  symptoms  occurs  in  the  case  of  nearly 
every  patient.  It  makes  its  appearance  toward  the  end  of  the 
withdrawal  period,  or  one  or  two  days  after  the  last  injection. 
It  is  to  be  regarded  as  rather  salutary  than  injurious,  and  if  it 
should  not  come  on  in  due  time  a  purgative  is  given  to  clear  the 
primes  vice.  Where  the  diarrhea  is  absent,  the  patient's  restless- 
ness is  greater.  Therefore  I  take  no  pains  on  the  first  and  second 
day  of  the  diarrhea  to  stop  it,  unless  it  becomes  excessive  or 
causes  painful  sensations  in  the  anus,  or  great  tenesmus.  The 
treatment  is  both  dietetic  and  medicinal.  For  diet  we  give  barley 
and  flour  gruel,  rice  and  rice  water,  sago,  toast,  mutton  tea, 
red  wine,  etc.  Opium,  of  course,  stands  first  among  the 
medicines.  .  .  . 

"There  are  notably,  during  the  treatment  of  morphinism, 
phases  of  depression  and  prostration,  periods  when  the  patient 
cannot  rise  from  his  armchair  or  his  bed  all  day  long;  when  he 
feels  as  if  there  were  no  life  in  his  arms  and  legs,  and  when  the 


Complications  Should  be  Prevented.  369 

moral  gloom  or  discouragement  intensifies  and  complicates  the 
physical  oppression.  It  is  then  that  alcohol  and  all  the  stimulants 
of  the  nervous  system  are  useful." 

AUTHOR'S  COMMENT. 

The  foregoing  extract  from  Erlenmeyer  fairly  rep- 
resents the  great  mass  of  literature  which  has  appeared 
on  this  subject  from  the  earliest  mention  of  it  to  within 
the  last  decade.  None  of  the  writers  seemed  to  have  any 
conception  of  the  pathology  of  the  condition  and  none 
advised  any  treatment  other  than  the  withdrawal  of  the 
drug  and  the  treatment  of  symptoms  as  they  arose. 

No  effort  was  made  to  remove  the  cause  of  these 
complications  and  to  thereby  thwart  their  development. 
In  fact,  the  entire  phenomena  following  the  withdrawal 
of  the  drug  were  looked  upon  as  an  entity  and  considered 
unavoidable. 

Even  in  the  symptomatic  treatment  which  they  ad- 
vised, alcohol  in  some  form  was  one  of  the  remedies 
almost  always  recommended,  and  this  was  extremely 
hurtful  rather  than  helpful. 

All  of  the  European  writers,  with  one  worthy  excep- 
tion, classed  narcotic  addiction  as  a  vice,  a  mere  habit, 
and  American  writers  contented  themselves  with  a 
parrot-like  repetition  of  their  views. 

At  the  time  the  author  took  up  the  study  of  this  sub- 
ject, not  an  original  idea,  not  a  helpful  suggestion  as  to 
either  the  pathology  or  treatment  of  drug  addiction,  had 
been  introduced  into  the  literature  of  the  subject,  except 
those  advanced  by  Jennings,  during  the  preceding 
quarter  of  a  century. 

The  question  of  pathology  was  either  dismissed  with 
the  statement  that  the  "pathology  is  nil,"  or  the  mani- 
festations accompanying  and  following  the  withdrawal 


24 


370  Narcotic  Drug  Diseases  and  Allied  Ailments. 

of  the  drug  were  attributed  to  some  obscure  nerve  lesion 
which  was  supposed  to  exist,  but  which  could  not  be 
demonstrated.  The  entire  subject  was  shrouded  in 
mystery  and  addiction  to  a  narcotic  drug  was  looked 
upon  as  an  untreatable  entity. 

In  the  matter  of  treatment,  practically  all  writers 
recommended  the  patient  be  "weaned"  from  his  drug, 
and  this  was  undertaken  in  one  of  three  ways,  that  is, 
by  gradually  or  rapidly  reducing  the  daily  allowance  or 
by  at  once  discontinuing  it.  Numerous  remedies  were 
suggested  for  the  relief  of  the  complications  which  at- 
tended or  followed  this  "weaning."  The  success  of  these 
measures  of  treatment  are  best  shown  by  the  statement 
of  one  who  depended  upon  them  for  relief  during  this 
"weaning"  process. 

It  is  barely  possible  that,  when  nothing  that  gave 
greater  assistance  was  available,  it  was  better  to  undergo 
such  an  ordeal  of  suffering  as  is  involved  in  this  "wean- 
ing" process  rather  than  to  continue  in  drug  slavery,  but 
most  patients  who  submitted  even  to  this  barbarous 
method  suffered  to  no  advantage,  because  the  numerous 
complications  which  followed  the  "weaning"  were  such 
as  to  force  a  return  to  the  use  of  the  opiate. 

The  following  example  of  the  progress  and  results 
of  this  "weaning"  process  is  taken  from  the  1909  Ameri- 
can edition  of  Jennings's  work,  pages  447-455.  It  speaks 
for  itself  as  to  the  mercifulness  and  efficiency  of  some  of 
the  methods  of  treatment  which  have  been  and  are  still 
advised  by  a  majority  of  writers: — 

"  EXPERIENCES  IN  DIFFERENT  EUROPEAN  SANATORIUMS. 

"The  following  extracts  are  from  La  Lutte,  by  Leon  Daudet, 
and  give  a  graphic  account  of  the  treatment  applied  in  a  German 
sanatorium  in  which,  says  the  author,  'the  most  distinguished 


A  Horrifying  Experience.  371 

chiefs  of  state,  savants,  artists,  and  writers  of  Europe  and 
America  are  treated  .  .  .  from  the  impulsive  sovereign,  who 
is  supposed  to  be  traveling  in  the  fiords,  to  ...  the  musician 
of  genius  who  translates  into  accents  of  love  the  long  tortures  of 
abstinence.' 

"The  patient  whose  case  is  related  was  only  what  is  called 
a  'petit  morphinomane,'  that  is  to  say,  he  had  taken  morphia  for 
only  a  year,  and  could  have  been  weaned  without  any  suffering 
by  a  proper  method.  As  it  was,  the  tortures  inflicted  on  him 
almost  reached  the  limit  of  human  endurance.  That  they  were 
by  no  means  exceptional  may  be  seen  by  comparing  this  case  with 
that  of  the  patient  (No.  X)  related  in  Appendix  No.  2,  and 
treated  by  the  same  plan  in  a  French  Maison  de  Sante. 

'I  had  had/  said  the  patient,  'my  injection  of  10  centi- 
grammes— instead  of  20 — at  eight  o'clock.  At  eleven  o'clock  I 
already  began  to  feel  the  craving  for  morphia.  I  tried  to  lose 
myself  and  asked  for  a  book.  They  gave  me  Goethe's  poems. 
I  did  not  even  open  the  volume,  but  remained  horror-struck  at 
the  prospect  of  the  long  wait,  which  was  to  continue  until  four 
o'clock. 

"  'At  twelve  I  forced  myself  to  eat,  but  was  without  appetite 
and  the  beer  I  drank  seemed  atrociously  bitter.  The  malaise  of 
craving  has  no  equivalent  in  the  normal  sensation  of  hunger, 
thirst  or  yearning.  It  is  a  combination  of  all  these  and  something 
more.  Fourmillement  of  all  the  muscles,  remeur  in  all  the 
nerves.  There  is  no  rest  for  body  or  mind.  I  was  obliged  to  get 
up  and  walk  toward  the  ground-glass  window,  through  which, 
however,  I  could  see  nothing.  I  would  then  return  to  the  rocking- 
chair,  counting  the  minutes  one  by  one  until  exactly  sixty  had 
gone  by.  By  this  time  it  was  half-past  one. 

"  'Fritz  then  advised  me  to  take  a  second  douche.  I  obeyed 
with  no  hope  of  relief,  but  whilst  I  was  under  the  burning  rain, 
surrounded  by  vapour,  I  forgot  my  wretchedness ;  .  .  .  I  was 
scarcely  dry  and  returned  to  my  room,  when  all  my  tortures 
recommenced. 


372  Narcotic  Drug  Diseases  and  Allied  Ailments. 

"  'At  three  o'clock  I  was  lying  on  the  ground  on  my  stomach, 
the  only  position  which  gave  me  any  relief,  trying  to  think  of 
nothing,  which  is  not  easy  when  the  word  opium  is  engraved  in 
every  one  of  our  cells  in  letters  of  fire.  Time  is  an  internal 
convention:  the  relation  of  the  hour  to  the  evolution  of  our 
environment.  Desire  increases  or  lessens  it.  Between  half-past 
three  and  four,  when  Uberthurn  came  to  see  me,  I  could  have 
affirmed  that  three  months  had  elapsed — three  months  of  anguish 
and  despair.  The  king  of  this  hell  held  in  his  hand  his  big 
syringe.  .  .  .  When  I  was  free,  I  had  only  felt  a  short  relief 
from  an  injection  of  15  centigrammes;  the  present  one,  terribly 
reduced,  gave  me  the  most  exquisite  delight.  Life  returned 
tumultuously  into  my  veins  with  its  feeling  of  hope  and  emotion. 
The  waves  of  physical  appeasement  passed  through  the  body, 
the  head  and  limbs,  with  voluptuous  vibrations.  I  sought  to 
restrain  my  tears  in  vain.' 

"After  a  short  respite  the  discomfort  returned  with  renewed 
severity.  The  patient,  whose  case  is  described  by  Dr.  Daudet, 
was  unable  to  eat  any  dinner,  and  'my  state,'  he  says,  'was  the 
same  as  during  the  afternoon,  but  with  the  aggravation  of  an 
almost  continual  nausea  interrupted  by  sudden  attacks  of  bilious 
vomiting.' 

"He  then  tried  the  effect  of  a  prolonged  warm  bath.  This 
gave  relief  while  he  was  in  the  water,  but  he  was  so  prostrate 
afterward  that  it  was  necessary  to  carry  him  back  to  his  room 
on  a  stretcher.  After  the  9  o'clock  injection  he  went  to  sleep, 
but  the  want  of  morphia  soon  made  itself  felt. 

"  'On  three  different  occasions  with  marvellous  patience  my 
attendant  took  me  to  the  bath,  then  to  the  douche,  then  back  to 
the  bath.  Inert,  I  allowed  him  to  do  what  he  pleased.  Calmed 
for  a  few  seconds,  then  distressed  by  abominable  cramps,  and 
tortured  by  the  idea,  which  had  become  an  obsession,  "If  it  is  as 
bad  as  this  now,  what  must  I  expect  to-morrow  and  afterwards  ?"  ' 

"His  suffering  becoming  unbearable,  it  occurred  to  him  to 
send  for  the  doctor,  but  he  was  told  it  was  quite  useless  to 


Indescribable  Anguish.  373 

expect  him  to  come  before  the  appointed  time,  as  he  never  allowed 
himself  to  be  disturbed  except  in  the  case  of  grave  syncope.  The 
idea  then  struck  him  to  simulate  a  fainting  fit,  but  he  was 
ashamed,  'for  what  is  allowable  in  an  ordinary  patient  is  not 
permitted  to  a  medical  man.'  .  .  .  From  12  to  3.30  P.M.  he 
went  a  dozen  times,  either  wheeled  to  the  douche  or  managed  to 
get  there  by  supporting  himself  against  the  wall,  his  legs  moving 
spasmodically  like  those  of  an  ataxic.  At  4  P.M.  he  was  asked 
whether  he  would  like  10  centigrammes  of  morphia  at  once,  and 
none  later,  or  5  immediately  and  the  same  quantity  in  the  evening. 
As  a  matter  of  course  he  asked  for  the  larger  dose. 

"By  dusk  he  felt  quite  as  ill  as  if  he  had  taken  no  morphine 
since  the  morning.  'Being  torn  by  an  immense  void,  trembling 
and  unstrung.'  The  doctor  then  came  to  pass  the  night  with 
him,  and  tried  to  amuse  his  patient  by  a  philosophical  discussion. 
He  explained  to  him  that  opium  acted  upon  by  abolishing  the 
latent  suffering  which  he  called  the  permanent  anguish  of  life. 
In  the  meanwhile  the  patient  was  writhing  and  rolling  on  his  bed, 
grasping  and  shaking  the  pillow. 

"  'Feeling  like  Montezuma  defending  himself  under  the  im- 
placable eye  of  his  jailers,  the  night  dragged  on  interminably,  and 
I  answered  only  by  groans  to  the  solicitations  of  my  attendant.  . 
.  .  .  Thoughts  of  my  studies  and  of  my  readings  came  back 
to  me  by  scraps  with  the  titles  in  English  and  German:  .  .  . 
"The  Opium  Habit  and  Its  Treatment."  .  .  .  "Pathologic 
der  Morphium  Sucht."  ' 

"Then  came  the  same  kind  of  hellish  sensations  which  have 
been  described  by  every  writer  since  De  Quincy.  Finally,  after 
an  unsuccessful  attempt  at  breaking  into  the  dispensary  to  procure 
a  larger  dose  of  morphia,  he  was  given  his  last  10  centigrammes 
by  the  doctor,  who  told  him  it  would  be  his  last  dose. 

"  'When  one  knows,'  he  said,  'that  one  is  not  to  have  any  more, 
one  is  less  unhappy  than  when  the  hope  remains  that  more  can 
be  obtained.' 


374  Narcotic  Drug  Diseases  and  Allied  Ailments. 

"The  following  twenty-four  hours  constituting  the  critical 
period  of  the  treatment,  the  doctor  promised  to  return  shortly 
and  remain  the  night.  Half  an  hour  afterwards  the  suffering 
had  returned  in  full  force. 

"  'I  was  at  the  height  of  the  crisis.  I  was  sobbing  and  rolling 
on  the  floor  in  the  middle  of  the  room,  whilst  Fritz,  the  attend- 
ant, murmured  sadly :  "Cheer  up,  Doctor !"  I  would  have  given 
anything  for  a  positive  pain  in  some  precise  part  of  my  body,  but 
like  a  vessel  in  a  black  tempest  I  was  attacked  on  every  side  but 
nowhere  in  particular.  A  general  obsession  held  my  brain  and 
gnawed  my  entrails,  accompanied  by  horrible  vertigo,  giddiness, 
and  insomnia.  Every  instant  I  was  obliged  to  change  my  position. 
At  one  moment  crouching,  then  bending  forwards,  wrestling  with 
myself  on  the  ground,  I  felt  at  the  same  time  an  abominable  lassi- 
tude and  an  imperious  want  of  movement.  My  bones  felt  as  if 
they  were  breaking.  Phosphorescent  flashes  passed  through  my 
eyes,  then  came  thirst,  at  first  a  simple  dryness  of  the  palate,  but 
ultimately  like  a  gimlet  that  was  being  thrust  into  the  stomach.' 

"During  this  phase  of  the  torture  drinking  is  forbidden,  as 
it  gives  rise  to  incoercible  vomiting,  and  the  patient  was  allowed 
only  to  suck  oranges.  When  at  last  matters  had  become  as 
atrociously  unbearable  as  possible,  he  was  carried  to  the  bath  and 
drank  as  much  water  as  he  could  swallow,  which,  whilst  appeasing 
momentarily  the  intolerable  thirst  and  bringing  back  life,  brought 
with  it  the  fury  for  the  opium. 

"  'On  returning  to  the  accursed  chamber  I  vomited  the  two 
quarts  I  had  imbibed  with  a  violence  that  doubled  me  up.  The 
doctor  did  not  scold,  but  contented  himself  with  saying,  "You 
had  better  keep  to  the  oranges ;  it  is  more  prudent."  ' 

"A  little  later  things  became  worse  still,  and  'death  seemed 
preferable  to  such  an  excess  of  suffering.  I  was,  however,  unable 
to  decide  whether  I  was  completely  or  only  partially  desirous  of 
it.  I  do  not  know  whether  I  should  have  used  a  revolver  had  it 
been  offered  to  me.  I  sought  nevertheless  for  some  means  of 


Unbearable  Sufferings.  375 

committing  suicide Then  I  got  up  and  began  to  turn 

round  like  a  circus  horse.  I  fell  down  without  doing  myself  any 
injury;  then  got  up  again  and  pushed  the  rocking-chair  in  front 
of  me.  These  grotesque  contortions  occupied  me  until  the  ap- 
proach of  night,  during  which  I  made  I  don't  know  how  many 
excursions  to  the  douche.  With  broken,  dislocated  limbs,  my 
mouth  like  a  lime-kiln,  the  brain  on  fire,  yearning  after  morphia 
like  a  lost  child  for  its  mother,  with  heart  and  senses  full  of  this 
idea  and  murmuring  the  name,  in  the  midst  of  my  nightmare,  I 
cursed  the  fit  of  courage  that  had  brought  me  to  this  prison.  I 
was  one  of  those  wretches  upon  whom  Providence  inflicts  the 
torture  of  passing  through  successive  ages  without  finding  repose 
anywhere.  I  was  the  wandering  morphinist.' 

"These  acute  sufferings,  which  had  continued  for  four  days, 
came  at  last  to  an  end.  But  after  what  is  known  as  the  'deliver- 
ance' two  months  elapsed  before  the  patient  was  able  to  leave  the 
sanatorium.  Experiencing  the  usual  consequences  of  the  brutal 
treatment  to  which  he  had  been  subjected,  the  following  is  his 
description  of  a  syncope  caused,  as  appears  to  be  usual,  from 
heart  failure : — 

"  'I  tried  to  get  up,  but  was  obliged  to  lie  down  immediately 

on  account  of  the  vertigo Objects  appeared  to  me 

double A  little  later  I  felt  my  heart  getting  slower. 

It  seems  as  if  I  were  dying  in  a  strange  sense  of  languor.  I  was 
recalled  to  life  by  the  buzzing  of  an  electric  coil.  Uberthurn  was 
applying  to  my  body  moist  pads  which  gave  me  violent  shocks, 
whilst  Fritz  was  making  me  breathe  vinegar.  In  this  way  I  went 
through  the  classical  syncope  of  the  thirtieth  hour.  I  may  say 
that  it  was  without  any  satisfaction.  A  dull  indifference,  like 
a  cloud  of  lead,  weighed  upon  me  and  upon  my  moral  horizon. 
My  throat,  still  bitter  and  dry,  was  full  of  repressed  sobs.  I 
sighed  to  myself,  "What  is  the  use  of  it  all  ?"  ' 

"It  is  unnecessary  to  quote  further  at  any  length.  The 
patient  remained,  after  the  syncope  described,  in  a  state  of 


376  Narcotic  Drug  Diseases  and  'Allied  Ailments. 

prostration  which  lasted  for  eight  days,  during  which  his  mental 
condition  was  one  of  hopeless  apathy,  'taking  no  interest  whatever 
in  anything — Si  ce  n'etait  tout  a  fait  le  gatisme  e'en  etait 
1'equivalent.' " 


CHAPTER  XX. 
REVIEW  OF  LITERATURE  (CONTINUED). 


OSCAR  JENNINGS,  PARIS,  FRANCE. 

THIS  entire  chapter  will  be  devoted  to  quotations 
from  and  a  review  of  the  writings  of  Jennings,  who,  in 
the  opinion  of  the  author,  contributed  more  original  and 
valuable  suggestions  to  the  literature  on  the  treatment 
of  morphinism  than  all  other  writers  who  lived  and 
wrote  during  the  nineteenth  century. 

Jennings's  original  work  was  done  during  the  last 
two  decades  of  the  nineteenth  century,  and,  while  he  is 
still  living,  he  had  not,  up  to  a  few  years  ago,  materially 
changed  the  position  announced  in  the  first  edition  of 
his  work.  To  the  students  of  the  literature  of  this  sub- 
ject his  work  is  of  the  deepest  interest  and  shows  how 
closely  an  earnest  searcher  after  truth  may  come  to 
reaching  the  very  truth,  and  yet  miss  it. 

Jennings  is  a  man  of  high  attainments  and  for- 
tunately,— or  unfortunately, — the  author  is  unable  to 
say,  was  addicted  to  morphine  himself.  It  is  true  that 
such  an  addiction  was  a  misfortune  to  him,  but  a  bless- 
ing to  others.  His  addiction  led  him  to  make  a  careful, 
thorough,  systematic  study  of  drug  addiction  and  to 
place  on  record  the  results  of  such  study,  illustrated  by 
his  own  personal  experience  in  carrying  out  the  treat- 
ment devised  by  him  upon  himself,  as  well  as  upon 
others. 

From  this  we  have  information  at  first  hand  and 
much  of  it  of  a  most  reliable  type.  Jennings,  however, 

(377) 


378  Narcotic  Drug  Diseases  and  Allied  Ailments. 

was  in  error  as  to  the  pathology  of  morphinism,  and, 
necessarily,  his  conclusions  as  to  the  manner  in  which 
the  treatment  he  used  effected  a  cure  were  faulty ;  how- 
ever, his  theory  as  to  how  his  remedies  acted  did  not 
prevent  them  from  being  of  the  greatest  value. 

In  a  clinical  study  of  the  subject  he  found  by  actual 
tests  that  persons  using  morphine  had  a  hyperacid  con- 
dition of  the  stomach.  This  he  assumed  to  be  due  to  a 
hyperproduction  of  hydrochloric  acid.  For  the  relief  of 
this  hyperacid  condition  of  the  stomach  he  administered 
bicarbonate  of  soda  in  large  doses,  usually  a  teaspoonful 
of  soda  or  a  draught  of  Vichy  water  equal  to  that,  and 
this  was  repeated  at  frequent  intervals  during  each  day 
and  for  many  days  in  succession. 

He  believed,  and  possibly  still  believes,  that  the 
neutralization  of  this  excess  of  acids  by  the  bicarbonate 
of  soda  overcame  the  pathological  condition  which  he 
considered  the  essence  of  the  craving,  or,  at  least,  one  of 
the  principal  factors  in  the  craving  for  morphine.  It  is 
evident  from  his  writing  that  he  considers  the  hyper- 
acidity the  essential  pathology  of  morphinism. 

Another  means  which  he  suggested,  and  used  to 
good  advantage,  was  a  Turkish  bath,  but  the  explanation 
he  gives  of  its  therapeutic  effect  is  that  it  aided  in  over- 
coming the  hyperacid  condition  by  the  elimination  of 
certain  acid  products  from  the  blood. 

Jennings  practised  the  gradual-reduction  method; 
in  fact,  a  very  gradual  form  of  the  gradual-reduction 
method. 

Patients  while  undergoing  that  were  observed  very 
closely.  The  tendency  to  be  restless  and  constantly  seek- 
ing to  be  in  motion  was  taken  as  an  indication  in  the 
treatment.  Jennings  practised,  and  had  his  patients 
practise,  motion  in  various  forms,  such  as  massage, 


Opinions  of  Jennings.  379 

bicycle  riding,  walking,  swinging  in  a  hammock,  sitting 
in  a  rocking  chair;  any  kind  of  motion  that  was  light 
and  not  fatiguing  was  encouraged. 

It  was  his  belief  that  by  thus  substituting  mechanical 
stimulation  for  the  morphine  stimulation  to  which  the 
nerve-centers  had  been  accustomed  the  demand  for  the 
morphine  was  in  a  measure  overcome.  This  measure 
of  relief,  in  his  opinion,  being  entirely  due  to  mechanical 
excitation  of  the  nerve-centers,  which  excitation  took 
the  place  of  and  in  a  measure  relieved  the  demand  for 
drug  stimulation. 

Another  symptom  to  which  Jennings  paid  especial 
attention  was  the  difficult  and  inefficient  heart  action. 
He  attributed  this,  also,  to  the  hyperacidity  of  the 
system.  But  in  its  treatment  he  pursued  the  most 
rational  methods,  and  these  gave  much  relief  and  helped 
him  materially  in  effecting  the  cure  of  his  patients. 

Prior  to  Jennings's  time,  and  by  most  writers  since 
that  time,  the  abstinence  symptoms  or  demands  for  mor- 
phine by  the  system  of  the  habitual  user  of  it  was  looked 
upon  as  an  unnatural  and  untreatable  entity  that  had  no 
real  basis,  except  in  the  perversion  of  the  will  of  the 
patient. 

Jennings's  study  of  his  own  case  convinced  him  of  the 
error  of  this  conclusion  and  he  undertook,  as  a  rational 
medical  man,  to  analyze  the  conditions  present  and  to 
treat  the  patient  accordingly. 

While  he  considered  the  craving  for  the  drug  the 
principal  factor  to  be  contended  with  in  the  management 
of  the  case,  he  applied  rational  therapeutic  measures  to 
meeting  the  indication  presented  by  the  condition  of  the 
patient.  He  says  that,  in  "analyzing  this  craving  and 
speaking  of  what  in  another  case  would  be  called  indica- 
tions for  treatment,  he  found  that  it  was  not,  as  it  had 


380  Narcotic  Drug  Diseases  and  Allied  Ailments. 

heretofore  been  allowed,  an  untreatable  entity,  but  that  it 
might  be  looked  upon  as  the  result  of  a  number  of  com- 
ponent distresses  and  capable  of  being  split  up  into 
factors  susceptible  of  entire  or  partial  relief." 

Thus  he  divests  his  mind  of  all  superstitious  ideas 
or  preconceived  notions  and  undertakes  to  treat  his 
patient  for  the  conditions  present  rather  than  mass  the 
symptoms  into  an  entity  and  treat  that. 

In  the  method  he  employed — the  gradual-reduction — 
the  craving,  the  imperious  demand  for  relief  of  suffering 
and  in  some  cases  for  the  sensation  of  stimulation  de- 
rived from  the  repeated  doses  of  the  morphine,  is  the 
most  prominent  factor  presented  by  these  cases;  it  is 
evident  that  all  writers  who  advocate  the  gradual-re- 
duction method  overestimate  the  importance  of  this 
factor.  It  does  not  constitute  the  essence  of  the  disease, 
as  they  suppose. 

While  Jennings  cured  his  patients,  it  is  evident  that 
he  did  not  cure  them  because  the  bicarbonate  of  soda 
neutralized  the  excess  of  hydrochloric  acid;  neither  did 
the  Turkish  bath,  by  helping  to  excrete  the  excess  of 
acid  from  the  system  alone,  or  the  motion,  by  satisfying 
the  demand  of  the  system  for  stimulation,  effect  the 
cure. 

These  agents  had  a  far  more  important  bearing  upon 
the  real  pathology  involved  in  the  undertaking  than 
Jennings  thought.  Their  action  was  not  curative  be- 
cause of  the  effects  he  attributed  to  them. 

After  the  quotations  from  Jennings's  works  which 
follow,  the  author  will  explain  how  each  of  these  agents 
contributed  to  the  cure  of  the  patient  in  the  light  of  the 
pathology  of  the  condition  as  at  present  accepted : — 

"It  may  seem  an  invidious  thing  to  say,  but  I  have  no  hesi- 
tation in  declaring  that  before  this  there  was  no  rational  treatment 


Morphinism  Not  Unbeatable  Entity.  381 

of  the  morphia  craving  founded  upon  therapeutic  indications. 
There  was,  in  fact,  no  treatment  of  the  craving  at  all,  which  is 
tantamount  to  saying  that  there  was  no  systematic  treatment  of 
the  morphia  habit. 

'The  so-called  'methods'  described  by  contemporary  writers 
consisted  of  suppressing  the  morphia  suddenly,  slowly,  or  semi- 
brusquely,  but  failure  was  always  the  final  result.  A  certain 
number  of  those  who  could  be  persuaded  to  give  up  their  liberty, 
when  they  did  not  die  suddenly  (Clifford  Allbutt),  or  commit 
suicide  (Levinstein),  were,  it  is  true,  sometimes  temporarily 
cured  after  indescribable  sufferings.  But  the  same  ignorance,  or 
rather  indifference,  concerning  the  means  of  alleviating  the 
craving,  extending  to  the  means  of  preventing  the  discomforts 
that  are  liable  to  occur  to  those  who  are  left  to  their  own  devices 
after  the  suppression,  in  nine  cases  out  of  ten  the  temporary 
suppression  was  followed  by  a  speedy  relapse. 

"I  will  say  at  once,  for  I  have  long  ceased  to  make  any  secret 
of  the  matter,  that  my  first  observations  were  made  in  my  own 
case.  The  only  treatments  then  known  being  the  'methods'  just 
spoken  of,  I  endeavored  to  analyze  and  to  dissociate  the  different 
factors  of  the  miserable  wretchedness  known  as  the  'morphia 
craving,'  and  to  discover  in  them  some  indication  of  treatment. 
It  soon  became  evident  that  to  call  an  attempt  at  suppression — 
whether  slowly  or  suddenly — a  'method'  was  an  absurdity.  The 
time  element  is  merely 'one  of  the  conditions  of  treatment,  and 
the  real  question — that  upon  which  the  whole  management  of  the 
suppression  turns — is  that  of  the  possibility  of  attenuating  and 
rendering  bearable  the  craving.  Analysing,  as  I  have  said,  this 
craving,  and  seeking  for  what  in  another  case  would  be  called 
'indications  of  treatment/  I  found  it  was  not,  as  it  had  hitherto 
been  allowed,  an  untreatable  entity,  but  that  it  might  be  looked 
upon  as  the  resultant  of  a  number  of  component  distresses,  and 
capable  of  being  split  up  into  factors  susceptible  of  entire  or 
partial  relief. 


382  Narcotic  Drug  Diseases  and  sillied  Ailments. 

"I  remarked  also  that  with  the  same  doses  and  the  same 
length  of  addiction,  the  discomforts  felt  by  different  patients 
differed  greatly  in  severity,  and  that  the  craving  was  always  in- 
creased at  times  by  a  certain  number  of  errors  and  imprudences 
the  morphia  habitue  always  commits;  and  that  it  could  be  pre- 
vented, on  the  other  hand,  in  a  remarkable  degree  by  certain 
dietetic  and  hygienic  observances,  and  remedied  by  a  number  of 
means  of  treatment  that  result  clearly  from  unmistakable  thera- 
peutic indications. 

"It  will  be  seen  further  on  that  every  one  of  the  treatments 
that  I  have  proposed  during  the  last  fifteen  years,  as  a  consequence 
of  these  observations,  has  since  been  endorsed  by  other  writers, 
and  that  the  means  I  pointed  out  as  resulting  from  therapeutic 
indications  are  now  generally  adopted  by  physicians  treating  this 
class  of  cases. 

"Some  writers  have  even  gone  so  far  as  to  adopt  one  of  my 
means  of  treatment,  and  to  magnify  its  importance  into  that  of 
an  adequate  method  by  itself.  Pichon  thus  credits  me  with  the 
invention  of  the  'physiological  method,'  which  consists  of  the 
administration  of  heart  tonics  alone. 

"Erlenmeyer,  too,  has  made  a  method  of  the  administration 
of  bicarbonate  of  soda,  given  to  neutralize  hyperacidity,  and 
which  he  terms  'chemical  demorphinisation.'  But,  unlike  Pichon, 
he  appropriates  the  discovery  to  himself,  although  I  have  been 
calling  attention  to  this  treatment,  as  will  be  seen  further  on,  ever 
since  my  first  publications,  and  had  almost  become  tired  of 
writing  on  the  subject,  before  it  had  occurred  to  him.  The 
Turkish  bath  has  also  been  proposed  as  a  complete  treatment 
lately,  but  for  the  present  I  shall  content  myself  with  mentioning 
the  fact. 

"It  is  scarcely  necessary  to  point  out  that  if  each  of  these 
plans,  which  alleviate  one  factor  of  the  discomfort,  has  by  itself 
been  found  efficacious  as  a  cure  in  the  hands  of  others,  the  three 
combined  must  give  a  greater  certainty  of  success. 


Elements  of  Craving — Jennings.  383 

"The  most  important  factors  of  the  craving,  as  will  be  seen 
further  on,  being  heart  depression,  hyperacidity,  and  nervous 
irritability,  the  relief  of  either  of  these  conditions  may  be  suffi- 
cient help  to  enable  a  patient  who  might  otherwise  be  unsuccessful, 
to  get  well;  but  there  will  be  a  much  better  chance  of  recovery 
without  suffering  by  the  application  simultaneously  of  the  means 
that  remedy  each  of  these  conditions,  and  so  prevent  or  alleviate 
the  craving  in  all  its  factors.  It  is  like  the  old  fable  of  the 
bundle  of  sticks  which  could  not  be  broken  as  a  whole,  but  which 
was  easily  disposed  of  when  they  were  taken  one  by  one. 

"How  far  suffering  can  be  prevented  by  the  judicious  applica- 
tion of  the  principles  I  have  laid  down  depends  upon  the  care 
that  is  taken,  not  only  in  punctually  and  exactly  carrying  out  the 
treatment,  but  also  in  guarding  against  such  imprudences  or 
accidents  as  exaggerate  craving. 

"I  can,  however,  now  affirm  that  I  have,  during  the  last  ten 
years,  had  abundant  opportunity  of  verifying  my  earlier  obser- 
vations, and  I  can  assert,  without  fear  of  contradiction,  that  when 
the  line  of  conduct  I  indicate  is  followed  intelligently,  the  craving 
can  often  be  entirely  prevented,  and  in  every  case  attenuated  to 
such  an  extent  that  it  is  as  nothing  in  comparison  with  any  other 
treatment,*  and  no  longer  constitutes  a  difficulty  to  anyone  who  is 
really  desirous  of  giving  up  the  addiction. 

"*  As  an  example  of  the  'failure'  of  my  treatment  I  will  mention 
the  case  of  a  young  man  sent  to  me  because  a  complete  result  could 
not  be  obtained  by  the  attending  practitioner.  The  patient  was 
taking  sparteine,  Vichy  water,  and  hot-air  baths,  and  was  therefore 
supposed  to  be  following  my  system,  but  could  not  get  beyond  the 
rectal-injection  period.  The  only  result  had  been  the  suppression  of 
the  syringe.  I  found  upon  questioning  him  that,  although  he  knew 
that  the  whole  treatment  was  intended  to  diminish  acidity,  he  had 
not  thought  there  was  any  objection  to  gorging  at  meals,  swilling 
beer  in  the  intervals,  and  emptying  the  larder  at  night  of  whatever  it 
contained.  He  looked  upon  this  regime  as  the  best  way  of  recuperating 
his  strength.  Whether  it  was  self-indulgence,  or  merely  a  pretext 
for  taking  morphia,  I  do  not  know;  but  as  he  would  not  change  his 
mode  of  life,  I,  of  course,  declined  to  have  anything  to  do  with  his 
treatment"  .  .  . 


384  Narcotic  Drug  Diseases  and  Allied  Ailments. 

"A  change  of  surroundings,  however,  is  preferable,  as 
morphia  habitues  are  generally  far  more  reasonable  with  strangers 
than  with  members  of  their  own  family,  whom  they  tyrannize 
from  force  of  habit.  .  .  . 

"There  must  be  regularity  as  regards  medicine;  regularity 
with  respect  to  meals ;  and  last,  but  not  least,  regularity  also  with 
respect  to  repose. 

"Whether  sleep  come  at  first  or  not,  the  light  should  be  ex- 
tinguished as  soon  as  the  last  dose  of  the  morphia  has  been  taken, 
and  reading  in  bed  strictly  forbidden.  The  pretext  for  reading 
in  bed  is  the  difficulty  of  sleeping,  but  in  the  morphia  habit,  even 
more  than  under  ordinary  circumstances,  it  is  the  habit  of  reading 
in  bed  that  aggravates  the  insomnia.  Whether  the  first  few 
nights  remain  sleepless  or  not,  the  patient  must  try  to  woo  back 
sleep  by  restoring  night  to  its  proper  purpose,  that  of  repose. 
It  stands  to  reason,  and  I  shall  refer  to  this  principle  more  fully 
further  on,  that  if  the  morphia  is  expended  in  providing  the 
intellectual  energy  necessary  to  enable  the  reading  of  a  book  to  be 
enjoyed  during  the  night,  its  effect  in  other  directions  is  lost,  and 
a  larger  quantity  than  otherwise  need  be  is  required  to  maintain  a 
state  of  comfort.  Those  who  know  nothing  about  morphia  will 
often  suggest  to  a  patient  in  a  state  of  want  to  take  a  book  and 
read.  But  morphia  patients  will  know  I  am  right  when  I  say 
that  such  a  recommendation  is  an  absurdity.  For  them  to  be  able 
to  read  it  is  necessary,  not  only  to  have  the  organs  of  vision  and 
the  intellectual  centre,  but  also  that  organs  and  centre  be  bathed 
with  a  sufficiently  strong  solution  of  morphia.  Reading  in  bed, 
then,  although  one  of  our  patients'  chief  pleasures,  must  be  given 
up,  in  order  to  make  the  morphia  go  as  far  as  possible.  .  .  . 

"I  endeavored  to  prove  to  him  that  the  man  who  complains 
of  the  want  of  some  little  indulgence  is  not  in  the  frame  of  mind 
requisite  for  successful  treatment,  for  if  he  realizes  at  its  proper 
price  the  inestimable  happiness  of  the  escape  from  morphia,  he 
ought  to  be  convinced  that  recovery  is  cheaply  purchased  at  the 


Substitution    of    Mechanical   for   Drug    Stimulation.     385 

cost  of  a  short  temporary  seclusion,  coupled  with  some  trifling 
interference  with  personal  habits.     .    .    . 

"It  is  no  part  of  my  task  to  enter  into  the  symptoms  of 
chronic  morphia  poisoning;  but,  as  my  treatment  is  based  upon  a 
certain  conception  of  the  nature  of  the  morphia  craving,  it  will 
be  as  well  to  give  at  once  my  theory  of  its  mechanism. 

"  'I  suppose/  I  said,  'that  the  want  of  special  stimulation,  felt 
as  the  morphia  craving-yearning,  reduces  itself  physiologically  to 
the  requirement  of  a  peculiar  mode  of  molecular  motion.'  The 
condition  of  ordinary  ennui  which  has  been  described  as  'a  sense 
of  tedium  in  activity/  having  its  source  in  a  want  of  mental 
occupation,  or,  in  other  words,  the  want  of  molecular  change  in 
certain  cerebral  centres,  is  intensified  into  the  distress  that  results 
from  'the  representation  of  a  future  in  which  such  cravings  will 
never  be  satisfied.'  This  'dissatisfaction/  by  inaction  of  the 
nervous  system,  is  associated  with  the  entoperipheral  craving  re- 
sulting from  the  diminished  impulse  to  those  organs,  and  more 
especially  the  heart,  which  subserve  nerve  activity.  Each  recur- 
rence of  the  sensation  is  probably  heightened  by  autosuggestion 
of  the  means  of  satisfaction,  and  by  the  abeyance  of  the  con- 
trolling power  of  the  will  over  the  morbid  automatism  of  the 
lower  centers,  which  are  polarised,  as  it  were,  into  fixed  yearning 
for  the  accustomed  stimulant.  From  this  tendency  to  an  accus- 
tomed molecular  motion  on  the  one  hand,  and  the  enforced 
inaction  from  want  of  the  necessary  stimulant  on  the  other,  arises 
a  condition  of  cellular  unrest  and  fatigue,  which  has  its  exact 
counterpart  in  the  external  habitus  of  the  patient. 

"The  feeling  of  intimate  restlessness  is  accompanied  by  an 
impossibility  for  the  individual  to  remain  at  repose;  but  if  he 
seeks  relief  by  walking  about,  he  is  soon  forced  by  fatigue  to  sit 
or  lie  down  on  a  couch  or  easy-chair,  when  no  sooner  has  a 
suitable  position  been  discovered  than  the  renewed  restlessness 
compels  him  to  be  up  and  moving. 

"It  is  this  imperious  tendency  to  movement  which  shows  itself 
also  in  involuntary  startings,  etc.,  that  furnished  me  with  one  of 

25 


386  Narcotic  Drug  Diseases  and  Allied  Ailments. 

my  first  indications  of  treatment — a  treatment  which  did  me  good 
service  when  I  had  nothing  better,  but  which  is  interesting  now 
only  as  showing  the  evolution  of  my  method.  Energy  resulting 
from  the  accustomed  pharmacodynamic  stimulus  is  required  to 
give  full  satisfaction  to  the  morphia  habitue,  but  motion  in  all  its 
modes  is  a  sedative  to  the  craving,  providing  always  that  it  be 
not  carried  to  fatigue. 

"Starting  from  this  point,  I  treated  my  first  case  by  the 
application  of  different  physical  stimulations,  such  as  faradisation, 
massage,  dry  friction,  heat,  galvanism,  etc.,  towards  the  end  of 
the  progressive  reduction,  and  I  found  that  I  was  able  to  effect 
sufficient  breaks  in  the  monotony  of  the  yearning  to  enable  the 
patient  to  wait  for  his  decreasing  doses  with  patience.  What  is 
generally  so  profoundly  discouraging  to  a  morphia  patient  is  the 
certainty  that  once  the  craving  is  felt,  it  will  go  on  with  increasing 
distress  until  the  morphia  is  administered.  In  the  case  I  allude  to, 
as  the  doses  became  less  frequent  and  less  considerable,  the 
periods  of  relative  comfort  became,  as  is  always  the  case,  shorter 
and  shorter,  and  a  strong  desire  for  the  morphia  was  felt  hours 
before  the  time  appointed  for  the  injection.  Although  other 
medicines  had  been  taken  in  the  course  of  the  reduction,  at  the 
time  the  physical-stimulation  plan  was  tried,  the  only  drugs  used 
were  bromide,  valerianate  of  ammonia,  and  bicarbonate  of  soda. 
The  result  of  the  experiment  was  entirely  successful.  The  patient 
who  had  taken  morphia  for  five  years,  and  cocaine  for  a  year  and 
a  half,  latterly  in  doses  of  over  20  grains  a  day  of  each,  and  who 
had  failed,  moreover,  previously  on  two  occasions  on  the  very 
brink  of  success,  managed  to  come  triumphantly  through  the 
ordeal.  Besides  the  different  stimulations  and  medicines  men- 
tioned, he  also  made  great  use  of  the  hammock,  in  which  he 
would  lie  exposing  his  limbs  for  hours  together  to  the  broiling 
sun. 

"It  was  upon  this  theory  of  the  substitution  of  another 
stimulus  to  the  brain  cells  for  the  accustomed  one  that  I  was 


Jennings's  Experience  Develops.  387 

led  to  use  trinitrine,  and  afterwards  nitrite  of  amyl.  Although 
these  agents  have  a  powerful  action  on  the  heart,  it  was  not  on 
this  account  that  I  selected  them,  and,  indeed,  if  a  medicine  could 
be  found  exercising  a  similar  action  upon  the  blood-vessels,  with- 
out stimulating  the  heart,  it  would  be  preferable.  What  the  heart 
requires  is  a  tonic  rather  than  a  stimulant,  the  action  of  which  is 
always  followed  by  a  corresponding  depression. 

"The  second  indication  of  treatment  is  to  be  found  in  the 
state  of  the  heart,  which  participates  in  the  general  vital  stoppage, 
giving  rise,  by  its  sluggish  action,  to  some  of  the  most  distressing 
symptoms.  .  .  . 

"The  most  important  functional  disturbance  as  regards  the 
craving  is  the  hypersecretion  of  acid  in  the  stomach  during  sup- 
pression, which  obviously  suggests  the  administration  of  bicar- 
bonate of  soda.  This  is  discussed  in  another  chapter. 

"To  sum  up,  the  want  of  morphia  makes  itself  felt  chiefly 
in  three  directions — (i)  a  condition  of  restlessness,  and  some- 
times of  pain,  depending  upon  the  want  of  an  artificial  stimulus 
to  the  brain  cells,  which  has  become,  as  it  were,  so  indispen- 
sable to  function  that  it  almost  represents  vital  force;  (2)  by 
a  failure  of  the  heart's  action  and  a  sluggishness  of  the  circula- 
tion, caused  by  the  want  of  the  natural  nervous  influx  to  the 
heart,  and  also  by  the  lessening  of  the  vis  a  fronte  through 
the  suspension  of  the  chemicovital  processes  in  the  tissues;  (3) 
an  excessive  secretion  of  acid  in  the  stomach.  Given  at  the 
proper  time,  the  suitable  means  are  quite  competent  to  allay  all 
craving.  But  for  the  cure  of  morphia  habit  something  more  is 
necessary.  .  .  . 

"But  irritable  and  restless  as  a  man  accustomed  to  other 
stimulants  may  feel  for  a  few  days  after  they  have  been  given  up, 
it  is  nothing  to  compare  with  the  vital  stoppage  resulting  from 
the  sudden  or  too  rapid  cessation  of  morphia.  It  is  no  exaggera- 
tion to  say  that  the  unfortunate  victims  of  the  habit  are  wholly 
and  absolutely  dependent  upon  their  accustomed  stimulant;  so 


388  Narcotic  Drug  Diseases  and  Allied  Ailments. 

much  so  that  it  has  almost  become  a  condition  of  existence.  The 
heart  will  scarcely  beat  without  it,  the  brain  only  thinks  by  it, 
and  digestion  is  entirely  dependent  upon  it.  In  a  word,  morphia 
to  its  unfortunate  slaves  is  the  synonym  of  vital  force. 

"It  might  seem,  then,  that  there  is  but  little  chance  of  escape 
from  a  thraldom  so  complete,  or  that,  at  the  very  least,  it  must  be 
necessary  to  employ  restraint.  Such  was  the  practical  conclusion 
of  a  discussion  at  one  of  the  medical  societies  in  London,  and 
such  is  the  opinion,  as  I  have  already  said,  of  the  leading  alienists. 
A  physician,  quoted  by  Dr.  Mattison,  expresses  himself  as 
follows:  'Let  him  (the  patient)  quit  it  short,  absolute  and 
entirely.  If  he  have  the  will  power,  trust  him;  if  he  cheats,  lock 
him  up,  put  a  Hercules  over  him  as  a  nurse.'  As  it  is  absolutely 
certain  that  no  one  whose  addiction  is  of  sufficient  standing  to 
warrant  the  expression  'morphia  habitue'  could  leave  it  off  sud- 
denly by  an  effort  of  the  will,  the  Herculean  nurse  would  become 
a  necessity.  Here  is  a  picture  of  the  treatment  by  the  same 
authority:  'All  substitutes  are  simply  a  prolongation  of  the 

agony  he  must  go  through The  patient  who  quits 

morphia  after  a  long-established  habit  suffers  from  insomnia, 
diarrhea,  nausea,  vomiting,  achings  all  over,  and  debility  to  such 

a  degree  that  it  is  a  marvel  how  he  lives All  this 

suffering  will  last  from  five  to  ten  days.  No  medicine  will  do  any 
good;  the  stomach  rejects  everything,  even  a  mouthful  of  cold 

water At  last,  after  several  centuries  of  torture,  little 

by  little,  and  without  medicine  or  substitutes,  nature  accomplishes 
the  cure.  This  terrible  treatment,  I  am  sure,  is  not  only  the  best, 
but  the  only  safe  one  to  cure,  and  secure  the  patient  from 
relapse.' 

"Dr.  Mattison  very  properly  protests  against  this  'brutal, 
barbarous,  and  inhuman  plan  of  treatment,'  and  shows  how 
mistaken  are  these  statements.  The  most  important  objection,  to 
my  mind,  is  that,  dreadful  as  are  the  tortures  inflicted,  they  do 
not,  as  a  matter  of  fact,  afford  any  safeguard  against  a 
relapse.  .  .  . 


Brutal  Methods  Condemned.  389 

"In  my  early  cases,  the  object  aimed  at  being  the  suppression 
of  morphia,  the  patients  were  allowed  too  much  latitude  in  other 
respects.  Nearly  every  morphia  habitue  is  sufficiently  well  ac- 
quainted with  the  literature  of  the  subject  to  be  more  than  a  match 
in  discussion  for  anyone  who  has  not  a  special  knowledge  of  the 
subject.  So  it  was  that,  when  I  first  began  to  make  the  treatment 
of  the  morphia  habit  a  special  study,  although  I  had  the  very 
best  reasons  for  thinking  that  certain  practices  were  imprudent, 
my  patients  were  always  able  to  quote  some  acknowledged 
authority  in  favour  of  their  course  of  conduct.  One  maintained 
that  he  was  helped  by  large  doses  of  alcohol — an  error,  notwith- 
standing the  books  that  endorse  this  opinion;  for  if  the  immediate 
effect  is  stimulating,  the  subsequent  reaction  makes  a  larger  dose 
of  morphia  necessary  to  combat  the  depression  of  the  heart  and 
vasomotors.  Another  would  insist  upon  having  chloral  at  discre- 
tion. A  third,  without  appetite  as  a  rule,  would  be  seized  with  a 
sudden  fit  of  boulimia,  and  eat  a  heavy,  indigestible  meal  in  the 
middle  of  the  night,  afterwards  suffering  from  dyspepsia,  for 
which  the  proper  treatment  would  be  an  emetic,  but  for  which 
a  morphia  habitue  always  exacts  an  extra  dose  of  morphia.  .  .  . 

"The  three  preceding  chapters  have  been  almost  textually 
reproduced  from  my  'Cure  of  the  Morphia  Habit'  of  1890,  and 
from  these,  and  from  the  passages  which  are  quoted  further  on, 
it  is  evident  that  every  element  of  the  treatment  I  employ  at 
present  had  been  already  used  by  me  at  that  date. 

"I  call  attention  to  this,  for,  although  the  greater  number  of 
writers  on  this  question  have  fully  recognized  my  claims  in  this 
matter,  certain  practitioners,  as  I  have  said  before,  have  found  it 
more  convenient  to  take  my  methods  without  acknowledgment 
than  to  devise  treatments  of  their  own,  and  have  even  gone  so 
far  as  to  claim  the  invention  of  these  treatments  for  themselves. 

"This  has  been  the  case  for  the  bicarbonate  of  soda  treat- 
ment, the  importance  of  which  will  be  seen  further  on,  and  also 
for  the  use  of  the  Turkish  bath,  which  an  irregular  practitioner 
is  also  exploiting  as  his  own  idea. 


390  Narcotic  Drug  Diseases  and  Allied  Ailments. 

"Believing  as  I  do  that  my  method  is  really  what  it  has  been 
termed,  the  physiological  one,  the  necessity  of  establishing  clearly 
my  priority  as  regards  these  means  of  treatment  must  serve  as  an 
excuse  for  the  repetition  which  the  description  of  them  as  ap- 
plied at  present  renders  unavoidable.  With  these  remarks,  I  pass 
on  to  the  consideration  of  my  actual  mode  of  treatment. 

"When  the  morphia  is  associated  with  some  other  addiction, 
the  first  thing  is  to  suppress  the  other  stimulant,  whatever  it  may 
be.  If  it  be  alcohol  or  cocaine,  there  is  no  difficulty  worth  speak- 
ing of  in  so  doing ;  indeed,  the  quantity  of  morphia  taken  becomes 
more  satisfying,  being  no  longer  antidoted,  as  it  were,  in  a  certain 
degree  by  the  other  stimulants  as  when  they  are  taken.  A 
medical  man  in  London  who  consulted  me  by  letter  was  astonished 
when  I  told  him  he  could  give  up  the  cocaine  without  trouble, 
having  been  accustomed  to  look  upon  this  as  the  most  difficult 
part  of  his  addiction.  He  wrote  shortly  after  to  say  that  he  had 
not  experienced  the  slightest  difficulty  in  carrying  out  my  in- 
structions. .  .  . 

"As  regards  the  rate  of  reduction,  I  have  always  been  a 
partisan  of  gradual  progression;  but  the  actual  time  necessary 
for  the  cure  of  any  given  case  depends  entirely  upon  the  thorough- 
ness with  which  the  craving  can  be  prevented  by  the  means 
adopted.  Starting  from  the  fact  that  it  is  possible,  without  any 
other  treatment  whatever,  to  wean  a  person  of  the  morphia  habit 
without  his  knowledge  by  a  sufficiently  slow  progressive  reduction, 
it  is  evident  the  slower  the  reduction,  the  less  distressing  is  likely 
to  be  the  craving.  The  plan  I  have  adopted  is  to  proceed  as  fast 
as  possible,  but  as  slowly  as  is  necessary,  to  effect  a  cure  without 
distress.  If  there  were  no  other  means  of  relieving  the  craving, 
the  treatment  would  resolve  itself  then  into  a  suppression  suffi- 
ciently gradual  for  each  patient,  but  this  is  no  longer  the  case. 

"The  next  great  factor  of  the  craving  is  hyperacidity  of  the 
stomach  and  organism  generally,  and  this  naturally  suggests  as  a 
treatment  the  administration  of  bicarbonate  of  soda.  For  thirteen 


Sodium  Bicarbonate,   Use  of.  391 

years  I  have  been  calling  attention  to  this  fact  in  English  publica- 
tions, and  although  still  apparently  unknown  in  England,  its 
importance  is  now  recognized  by  every  writer  on  the  Continent, 
Professor  Joffroy,  of  the  Paris  School  of  Medicine,  being  the  last 
one  to  endorse  it  and  to  recognize  my  claims  to  its  authorship. 
It  may  seem  strange  to  make  a  therapeutic  agent  like  bicarbonate 
of  soda  play  an  important  part  in  the  treatment  of  the  morphia 
habit,  but  some  go  even  further  than  this  and  make  it  little  less 
than  a  panacea.  Erlenmeyer,  who  labours  under  the  impression 
that  he  was  the  first,  in  1895,  to  suggest  its  use,  as  I  have  said 
already,  has  even  given  this  means  of  treatment  the  name  of 
'chemical  demorphinisation.'  As  I  pointed  out  in  four  different 
publications  before  that  date  that  hyperacidity  was  an  important 
factor  of  the  craving,  and  insisted  in  each  instance  upon  the  value 
of  bicarbonate,  the  only  thing  that  can  be  claimed  truly  by  Erlen- 
meyer is  to  have  given  a  high-sounding  name  to  one  of  my 
discoveries,  and  to  have  correspondingly  exaggerated  its  im- 
portance. .  .  . 

"Bicarbonate  relieves  the  craving  in  so  far  as  it  is  caused  by 
overacidity,  in  the  same  way  that  heart  tonics  relieve  it,  qua 
cardiac  sluggishness,  and  nothing  more,  but  it  is  none  the  less 
satisfactory  to  find  that  according  to  others  I  have  here  again 
understated,  rather  than  exaggerated,  the  value  of  my  treat- 
ment. .  .  . 

"Various  other  means  of  relief  may  be  applied  according  to 
symptomatic  indications,  but  the  last  of  my  therapeutic  triad  is 
the  hot-air  bath.  .  .  .  • 

"And  further  on : — 

"  The  moderate  restlessness  which  occurs  when  patients  are 
properly  treated  disappears  entirely  in  the  hot  room  of  the 
Turkish  bath ;  and  the  subsequent  massage  and  cold  douche  form 
the  most  perfect  sedative  that  a  morphia  patient  can  be  allowed. 
There  is  no  better  means,  moreover,  of  dealing  with  the  revival 
of  the  craving  that  occurs  from  time  to  time,  especially  under  the 
influence  of  indigestion.' 


392  Narcotic  Drug  Diseases  and  Allied  Ailments. 

"In  several  of  the  cases  reported,  moreover,  its  use  is  espe- 
cially noted;  it  is  mentioned  in  one  that  for  the  last  week  the 
patient  took  Turkish  baths  regularly. 

"As  a  matter  of  fact,  I  used  the  Turkish  baths  long  before 
1890,  for  in  a  reprint  of  my  paper  in  the  Encephde,  in  1887,  I 
stated  it  was  'an  excellent  means  of  calming  the  agitation  caused 
by  attempts  at  suppression,  giving  rise  to  sensations  that  resemble 
morphia,  and  being  followed  by  lassitude  most  agreeable  to  the 
agitated.' 

"And  speaking  of  the  after-treatment  of  the  case  on  which 
the  paper  is  founded: — 

"  'Whenever  the  necessity  of  a  tonic  or  a  calmant  is  felt,  he 
has  recourse  to  the  Turkish  bath,  and  it  would  be  difficult  to  find 
a  more  efficacious  means.' 

"In  the  Medical  Annual  ( 1894)  I  am  even  more  emphatic  as 
to  its  value  and  to  its  importance  as  a  regular  part  of  my  method. 
And  here  again  I  have  certainly  not  overstated  my  case,  for  the 
author  of  a  Montpellier  thesis  makes  alternate  douching  with 
hot  and  cold  water  a  method  by  itself,  and  there  is  now  an  institu- 
tion for  the  cure  of  the  morphine  habit  by  hot-air  baths  alone. 
It  is  highly  probable  that  other  means  are  used  concurrently,  for 
however  valuable  the  hot-air  bath  may  be,  the  cure  will  never  be 
too  easy,  and  there  can  be  no  reason  for  rejecting  any  one  of  the 
means  that  have  been  proved  to  be  useful.  In  a  recent  case, 
wishing  to  test  the  value  of  the  baths  alone,  a  very  unmanageable 
patient  of  mine  was  submitted  to  this  treatment,  but  he  contrived 
to  cheat,  and  it  did  not  prove  nearly  as  satisfactory  as  the 
exponent  of  this  treatment,  who  was  directing  it,  had  promised. 
Being  afterwards  placed  under  conditions  which  prevented  all 
deception,  the  system  of  rectal  injections  with  bicarbonate  of 
soda  was  substituted,  and  he  was  cured  without  knowing  when 
he  had  passed  the  Rubicon.  I  am  not  desirous,  in  alluding  to  this 
case,  of  detracting  from  the  value  of  the  hot-air  bath,  inasmuch 
as  here  again,  whatever  may  be  its  value,  the  idea  is  my  own, 


Hyperacidity  Not  the  Pathology.  393 

and  forms  an  integral  part  of  my  method  of  treatment.  It  is 
better,  however,  not  to  expect  from  it  more  than  it  can  do,  and 
in  most  cases,  however  great  the  relief  obtainable  from  the  bath, 
it  stands  to  reason  that  it  cannot  be  as  helpful  alone  as  the  asso- 
ciation of  the  three  different  means  corresponding  to  the  three 
chief  indications  of  treatment. 

"The  effect  of  the  bath  is  due  in  part  no  doubt  largely  to  its 
tonic  and  sedative  action,  but  it  may  also  act  as  an  eliminator  of 
some  excitant  of  craving.  This  may  possibly  be  the  oxydi- 
morphine  which  is  formed  in  the  body,  and  considered  by  Marme 
as  its  chief  cause,  experiment  having  shown  that  oxydimorphine 
when  injected  into  the  system  in  a  virgin  subject  produces  the 
symptoms  of  craving.  It  may  be  also,  as  I  have  always  main- 
tained, that  it  is  a  moderator  of  acidity,  and  this  would  explain 
its  value  in  the  after-treatment,  when  the  ex-habitue,  unless  ex- 
tremely abstemious,  is  saturated  with  acidity,  and  when  it 
would  be  difficult  to  explain  the  spurious  cravings  by  oxydi- 
morphine.* .  .  . 

"The  three  means  of  treatment  that  have  been  chiefly  dis- 
cussed up  to  the  present — heart  tonics,  bicarbonate  of  soda,  and 
hot-air  baths — constitute  the  therapeutic  triad  that,  together  with 
the  special  mode  of  reductions  by  means  of  rectal  injections,  make 
up  the  method  I  advocate." 

AUTHOR'S  COMMENT. 

The  proposition  advanced  by  Jennings  is  in  effect 
that  the  presence  of  an  excess  of  hydrochloric  acid  in  the 

"*  It  has  been  thought  that  the  hot-air  bath  might  act  as  an 
eliminator  in  chronic  conditions  associated  with  uric  acid,  but  insig- 
nificant quantities  only  have  been  excreted  by  forced  sweating.  Until 
it  is  otherwise  demonstrated  I  shall  continue  to  look  upon  the  factor 
of  the  craving  that  is  remedied  by  the  hot-air  bath  as  mainly  a  'state 
of  the  body,'  much  more  than  a  'something  to  be  excreted.'  The 
hyperacidity  is  due  to  a  depression  of  function,  as  is  also  the  heart- 
failure;  and  it  is  also  by  remedying  functional  depression  that  the 
hot-air  bath  is  chiefly  useful."  .  .  . 


394  Narcotic  Drug  Diseases  and  Allied  Ailments. 

stomach  is  due  to  a  hyperproduction  of  hydrochloric 
acid,  and  that  this  is  the  pathology  of  the  addiction. 

Hydrochloric  acid  is  a  normal  digestive  secretion  and 
its  presence  in  the  stomach  is  essential  to  stomach  diges- 
tion. It  may  be  produced  in  excess  or  there  may  be 
underproduction.  But  even  when  there  is  not  a  normal 
quantity  secreted,  there  may  be  more  than  a  normal 
quantity  in  the  stomach. 

When  stomach  digestion  is  completed  the  entire 
stomach  content  is  a  strongly  acid  solution,  the  acidity 
being  due  to  the  presence  of  hydrochloric  acid.  "This 
strongly  acid  solution  is  passed  into  the  duodenum  and 
there  it  comes  in  contact  with  the  alkaline  secretion  from 
the  liver  and  pancreas.  These  neutralize  the  excess  of 
acids  and  then  the  other  parts  of  the  meal,  which  are 
not  digestible  in  the  presence  of  an  acid  medium,  are 
digested  by  the  action  of  the  pancreatic  and  hepatic 
secretions. 

Now,  the  presence  of  an  excess  of  hydrochloric  acid 
may  be  due  either  to  an  underconsumption  or  overpro- 
duction of  hydrochloric  acid.  The  presence  of  an  excess 
of  acid  in  the  stomach  of  morphine  habitues  is  evidently 
due  to  underconsumption  of  acid  rather  than  to  over- 
production. 

The  restricted  intestinal  motion,  the  semiparalyzed 
condition  of  that  tube,  does  not  admit  of  the  ready  down- 
ward passage  of  the  stomach  contents.  This  semipara- 
lyzed condition  of  the  intestinal  tube  dams  back  and 
forces  the  too-long  retention  of  the  stomach  contents. 
The  delayed  passage  of  this  food  from  the  stomach 
probably  excited  some  additional  secretion  of  hydro- 
chloric acid,  but  this  would  not  have  been  sufficient  to 
be  considered  an  excess  had  intestinal  motion  been  such 
as  to  have  permitted  the  prompt  downward  passage  of 
stomach  contents. 


Sodium  Bicarbonate,  Effect  of.  395 

It  was,  in  the  author's  opinion,  this  underconsump- 
tion or  delayed  consumption  of  hydrochloric  acid  which 
Jennings  saw  and  regarded  as  the  pathology  of  mor- 
phinism. 

When  the  motility  of  the  intestinal  canal  is  thor- 
oughly excited  and  maintained,  hyperchlorhydria  is  not 
present  in  morphine  habitues,  either  while  taking  mor- 
phine or  under  treatment  for  addiction.  But  someone 
will  ask,  If  this  is  the  case  how  did  Jennings's  bicarbo- 
nate of  soda  help  cure  his  patients? 

We  have  seen  in  the  earlier  chapters  of  this  work 
that  the  essential  pathology  of  drug  addiction  is  a 
toxemia,  the  toxins  being  of  drug,  intestinal,  and  auto- 
origin;  that  the  system  is  intensely  saturated  with 
poisons  of  all  these  types,  and  that  their  elimination 
prevents  most  of  the  symptoms  incident  to  the  with- 
drawal of  morphine.  This  elimination  is  carried  out 
principally  through  the  bowel  by  the  effects  of  pur- 
gatives. 

Now,  in  the  administration  of  bicarbonate  of  soda, 
Jennings  never  thought  of  giving  a  purgative;  he  was 
giving  an  antacid.  He  believed  that  its  antacid  effect 
was  that  which  proved  beneficial  to  his  patients. 

Teaspoonful  doses  of  bicarbonate  of  soda  taken  into 
the  stomach  in  the  presence  of  an  excess  of  hydrochloric 
acid  not  only  neutralize  the  acid,  but  in  neutralizing  it 
bicarbonate  of  soda  is  broken  up  and  chloride  of  sodium 
formed  in  its  stead.  Now,  the  chloride  of  sodium  is  one 
of  the  most  reliable  of  the  saline  cathartics.  It  does  not 
act  so  promptly  or  so  freely  as  some  of  the  other  salines, 
but  its  action  is  equally  sure. 

This  action  carries  away  not  only  the  excess  of  acid 
and  other  products  in  the  upper  part  of  the  intestinal 
canal,  but  empties  the  canal,  producing  a  reliable  degree 
of  peristalsis. 


396  Narcotic  Drug  Diseases  and  Allied  Ailments. 

The  frequent  repetition  of  these  doses  of  bicarbonate 
of  soda  kept  up  free  elimination  by  the  bowel,  and  it  was 
in  that  way  rather  than  in  neutralizing  the  acid  that 
Jennings's  treatment  benefited  the  patient. 

The  same  is  true  of  the  Turkish  bath.  That  is  to  say, 
the  Turkish  bath  promoted  free  diaphoresis,  and  that 
action  took  out  through  the  pores  of  the  skin  large  quan- 
tities of  toxic  matter,  not  only  the  excess  of  acids,  if 
present,  but  of  all  other  toxins  with  which  the  patient 
was  saturated. 

These  toxins  were  not  necessarily  acid;  in  fact,  it  is 
doubtful  whether  they  were  acid  at  all;  there  possibly 
was  a  small  amount  of  free  uric  acid  in  the  blood,  but, 
aside  from  that,  the  blood  would  hardly  contain  free 
acids,  being  an  alkaline  solution. 

But  the  blood,  as  well  as  every  gland  and  cell  in  the 
body,  was  saturated  with  toxic  matter  and  the  free 
sweating  in  the  Turkish  bath  carried  off  large  quantities 
of  these  toxins,  and  the  patient  was  relieved  of  the  dis- 
tress due  to  their  irritating  effect  on  the  central  nervous 
system. 

Again,  the  benefits  derived  from  continuous  motion, 
massage,  etc.,  were  of  the  same  character.  Instead  of 
this  substitution  of  mechanical  for  drug  stimulation 
merely  satisfying  these  centers  by  supplying  stimulation, 
to  which  they  had  been  accustomed,  this  stimulation  ex- 
cited greater  activity  of  these  centers. 

This  increased  activity  caused  them  to  generate  and 
send  to  all  the  structures  more  efficient  motor,  secretory, 
and  excretory  impulses,  thereby  stimulating  all  the  ex- 
cretory organs  and  causing  them  to  throw  off  a  larger 
quantity  of  the  toxic  matter  with  which  the  system  was 
surcharged,  and  it  was  in  this  way  that  free  motility 
benefited  his  patients. 


Benefits  of  Mechanical  Stimulation  Explained,         397 

Doubtless  the  stimulation  of  the  disordered  nerve- 
centers  did  bring  a  measure  of  temporary  relief,  but  its 
principal  curative  value  was  evidently  due  to  the  in- 
creased elimination  which  it  promoted. 

Thus,  we  see  that,  from  all  three  of  his  means  of 
relief  for  craving  or  distress,  we  have  the  same  resulting 
effect — that  of  elimination,  and  elimination  is  the  sheet- 
anchor,  in  fact  the  bed  rock,  of  the  successful  treatment 
of  toxic  conditions,  of  which  morphinism  is  the  most 
striking  example. 

The  author  feels  sure  that  Jennings's  explanation 
of  the  difficult  heart  action  was  also  erroneous.  He 
attributes  "difficult  heart  action,  failure  of  heart  action, 
and  sluggish  circulation  to  want  of  natural  nervous 
influx  to  the  heart  and  also  to  the  lessening  of  the  vis  a 
fronto  through  the  suspension  of  the  chemicovital 
process." 

It  is  evident  that  this  does  not  account  for  that  symp- 
tom, since  it  is  not  seen  at  all  when  the  system  is  cleansed 
of  the  toxic  matter  and  the  portal  system  disengorged. 

In  the  treatment  of  a  narcotic  habitue  when  the 
primary  step  in  the  treatment  is  to  thoroughly  cleanse 
the  system  of  toxic  matter  by  sufficient,  well-directed 
courses  of  purgation,  by  which  the  portal  engorgement 
is  also  overcome,  the  heart  action  is  not  in  any  wise 
embarrassed  and  the  circulation,  instead  of  being  ineffi- 
cient and  unreliable,  is  very  much  better  than  when 
morphine  was  being  regularly  used. 

Again,  as  soon  as  the  intestinal  canal  is  brought  into 
active  motility  by  stimulation  of  the  motor  centers  with 
strychnine,  the  secretions  of  the  stomach  and  the  upper 
part  of  the  intestinal  canal  are  promptly  carried  down- 
ward. The  acid  contents  of  the  stomach  are  brought 
into  contact  with  the  alkaline  secretions  in  the  intestines 


398  Narcotic  Drug  Diseases  and  Allied  Ailments. 

and  the  acid  is  there  neutralized.  When  this  is  done, 
and  as  soon  as  it  is  done,  the  hyperacid  condition  present 
at  the  beginning  disappears  entirely  and  is  not  after- 
ward seen;  that  is,  it  is  not  afterward  seen  if  the  bowel 
is  kept  acting  normally. 

In  fact,  after  that,  instead  of  there  being  an  excess  of 
hydrochloric  acid,  in  many  cases  the  author  has  found  it 
deficient,  and,  as  a  remedy,  has  frequently  administered 
hydrochloric  acid,  with  the  very  best  results. 

These  clinical  results  show  clearly  that  in  Jennings's 
case  the  hyperacidity  was  due  to  underconsumption  of 
hydrochloric  acid  rather  than  to  an  overproduction  of 
it. 

Not  only  that,  but  the  relief  of  the  portal  system,  the 
cleansing  of  the  system  from  toxic  matter,  overcomes 
most  of  the  other  distressing  reactionary  symptoms  that 
attend  the  withdrawal  of  morphine.  The  symptoms  of  a 
nervous  and  mental  character  continue  for  two  or  three 
days,  that  is,  until  the  secondary  effects  of  morphine 
become  exhausted,  and  then  these  subside  without 
further  treatment,  and  no  craving  for  the  drug  remains. 

It  is  true  the  patient  is  anemic  and  must  be  built  up 
from  the  rundown  condition  induced  by  the  morphine, 
but  he  is  placid,  can  lie  quietly  on  the  bed,  passes  his 
time  in  comfort,  and  eats  and  digests  a  liberal  quantity 
of  nourishment.  It  is  true,  if  he  overtaxes  his  digestive 
organs,  and,  as  a  consequence,  there  is  an  acetic  fermen- 
tation, he  will  have  a  hyperacid  condition  of  the  stomach, 
but  it  will  not  be  hyperchlorhydria ;  it  would  be  simply 
an  acetic  fermentation  as  in  any  other  case  of  acute 
indigestion.  This  condition  is  promptly  relieved  by  an 
emetic  or  an  active  cathartic. 

It  is  really  surprising,  when  one  reads  Jennings's 
excellent  work,  to  see  how  nearly  he  came  to  reaching 


Value  of  Jennings  s  Work.  399 

the  conclusion  that  the  toxic  condition  of  the  system 
was  the  cause  of  all  the  distressing  symptoms,  and  yet 
how  utterly  he  failed  to  recognize  that  fact.  He  is  to  be 
congratulated,  however,  on  the  thoroughness  with  which 
he  studied  the  subject,  and  especially  his  own  case,  and 
with  the  accuracy  with  which  he  recorded  the  conditions 
presented. 

He  is  also  to  be  congratulated  upon  the  results  ob- 
tained in  the  treatment  of  these  cases  when  he  was 
handicapped  by  error  as  to  the  real  pathology  of  the 
conditions  with  which  he  was  contending,  his  treatment, 
strictly  speaking,  being  empirical. 

The  means  he  used  were  such  as  would  have  been 
helpful  had  he  had  a  clearer  view  of  the  pathology,  but 
they  are  not  the  ones  upon  which  he  would  likely  have 
placed  his  main  dependence  had  a  clear  conception  of  the 
pathology  been  his. 

The  fact  that  all  these  symptoms  against  which  he 
strove  so  constantly  disappear  when  the  toxic  condition 
of  the  system  is  overcome  is  the  best  proof  the  author 
has  to  offer  as  to  the  correctness  of  his  views  of  the 
pathology. 

The  author  considers  it  a  fortunate  thing  that  he  had 
not  read  Jennings's  work  before  he  undertook  his 
original  clinical  study  of  this  subject,  because,  had  he 
done  so,  he  might  have  been  influenced  by  the  doctor's 
views  to  such  a  degree  as  to  have  missed  the  object  of 
his  study — the  determination  of  the  real  pathology  of 
narcotic  disease  and  devising  a  rational  treatment  for 
the  same. 

As  it  was,  having  fully  satisfied  himself  that  the 
teachings  of  the  writers  whose  works  he  had  read  were 
totally  erroneous,  he  was  left  with  his  mind  a  blank,  as 
it  were,  on  the  subject  and  in  condition  to  pursue  his 


400  Narcotic  Drug  Diseases  and  Allied  Ailments. 

investigation  guided  only  by  the  general  principles  of 
medicine. 

After  having  read  some  of  the  author's  papers  Jen- 
nings, in  1906,  mailed  him  a  copy  of  his  book,  English 
edition  of  1901,  and  this  was  the  first  that  the  author 
had  seen  of  Jennings's  work.  The  conclusions  of 
Jennings  and  the  author,  as  to  the  effects  and  value  of 
sparteine  in  these  cases,  are  identical,  but  each  was 
based  upon  his  own  clinical  study,  the  author  having 
been  led  to  try  the  use  of  sparteine  by  the  teachings  of 
Bartholow. 


CHAPTER  XXI. 

REVIEW  OF  LITERATURE  (CONTINUED). 


AMERICAN. 

UP  to  within  the  last  few  years  no  American  author 
had  announced  the  holding  of  views  which  differed 
materially  from  the  recorded  views  of  the  European 
writers ;  in  fact,  the  views  of  the  European  writers  seem 
to  have  been  accepted  as  final,  and  they  were  simply 
reiterated  by  those  Americans  who  thought  it  worth 
while  to  write  anything  at  all  on  the  subject. 

The  author  will  not  undertake  to  reproduce  exten- 
sively the  writings  of  American  authors.  There  has 
been  such  unanimity  of  opinion  among  them  until  a  very 
recent  date  that  one  article,  taken  from  Osier's  "Modern 
Medicine,"  may  be  regarded  as  fairly  representative  of 
all. 

This  article  is  selected  partly  because  its  author, 
Alexander  Lambert,  has  lately  made  other  contributions 
to  the  literature  of  this  subject,  which  writings  will  be 
considered  later  in  this  chapter.  This  article,  taken  with 
Lambert's  more  recent  writings,  gives  a  more  clear  idea 
of  his  position. 

OSLER'S  "MODERN  MEDICINE." 
ARTICLE  BY  ALEXANDER  LAMBERT. 

"Indulgence  in  morphia  is  a  vice  of  recent  years ;  it  has  taken 
the  place,  especially  in  large  cities,  of  the  preparations  of  crude 
opium.  The  readiness  and  cheapness  with  which  morphia  can  be 
obtained  and  the  ease  with  which  hypodermic  syringes  can  be 
bought  have  made  this  vice  a  widespread  curse.  .  .  . 

26  (401) 


402  Narcotic  Drug  Diseases  and  Allied  Ailments. 

"The  hypodermic  use  of  morphia  is  the  most  seductive  form 
of  the  habit  and  the  hardest  to  break;  some  patients  seem  to 
require  the  sensation  of  the  needle-thrust  in  order  to  be  satisfied. 
What  is  sought  in  most  cases  is  the  feeling  of  exaltation,  strength, 
and  mental  vigor,  with  relief  from  pain  or  ennui,  the  drowning  of 
sorrow,  or  the  killing  of  the  hopeless  realization  of  despair  and 
failure.  Morphia  does  this  as  long  as  the  desired  effect  lasts. 
The  duration  of  this  varies  in  different  individuals  and  is  longer 
in  the  beginning  because  the  toleration  for  the  drug  is  rapidly 
acquired  and  the  time  between  doses  must  be  continually  short- 
ened or  the  dosage  increased,  and  finally  both  of  these  means  must 
be  used  to  obtain  the  desired  results.  .  .  . 

"In  the  morphia  addictee  there  are  practically  three  stages, 
which,  although  shading  into  each  other,  can  still  be  recognized: 
exaltation,  intoxication,  and  cachexia.  The  first  is  one  of  enjoy- 
ment, happiness,  and  satisfaction.  When  the  effect  has  subsided 
it  is  followed  by  malaise,  a  feeling  of  restiveness,  and  painful 
anxiety,  which  a  renewal  of  the  dose  takes  away.  The  effects  of  a 
single  dose  will  sometimes  last  for  twenty-four  hours,  but  this  is 
soon  reduced  to  twelve,  then  to  six,  then  to  three  hours,  then  to 
minutes  instead  of  hours,  and,  finally,  the  exaltation  ceases,  and 
he  must  take  the  drug  to  quiet  the  intense  craving  and  the  pains 
of  abstinence.  .  .  .  Morphinists  will  invariably  lie  about  their 
vice,  because  in  the  early  stages  they  feel  the  disgrace  and  have 
enough  moral  sense  left  to  endeavor  to  hide  it.  If,  however,  they 
have  just  taken  their  morphia  or  are  assured  of  sufficient  dosage 
to  keep  them  comfortable,  they  do  not  necessarily  lie  about  other 
matters.  But  when  the  craving  for  the  drug  is  upon  them,  there 
is  nothing  to  which  they  will  not  stoop  to  obtain  it.  Lying, 
thieving,  begging  in  the  street,  prostitution  itself,  are  to  them  all 
justifiable  means  to  obtain  the  drug  and  smother  the  irresistible 
craving.  .  .  . 

"The  reflexes  are  very  variable.  Disturbances  of  the  general 
sensibility  are  often  marked  and  vary  greatly;  there  are  often 


Some  Popular  Fallacies.  403 

paresthesias  and  sometimes  intense  neuralgic  pains.  Others  show 
marked  anesthesia,  which  may  be  confined  to  one  side  of  the 
body.  More  often  there  is  hyperesthesia,  and  the  sole  of  the  foot 
becomes  so  painful  that,  when  it  is  touched  to  the  floor,  it  gives 
a  sensation  of  burning,  and  the  patient  can  only  walk  with  short, 
jumping  steps.  Rodet  considers  this  form  of  hyperesthesia  as 
very  characteristic  of  chronic  morphinism.  The  tactile  sensibility 
is  usually  diminished  or  abolished.  .  .  . 

"Troubles  of  digestion  are  among  those  most  noticed  by  the 
patients  themselves ;  in  the  early  stages  there  is  nausea,  vomiting, 
and  anorexia,  which  do  not  persist  for  a  very  long  time.  There 
is  often  an  intense  thirst;  the  breath  is  very  offensive  and  of  a 
peculiar  odor,  often  spoken  of  as  being  so  characteristic  as  to 
designate  the  morphinist  by  those  who  are  brought  in  contact 
with  many  of  these  patients.  They  are  markedly  constipated  and 
this  often  alternates  with  attacks  of  diarrhea;  their  stools  are 
bloody  and,  during  the  period  of  constipation,  may  be  as  infre- 
quent as  once  or  twice  a  month.  .  .  . 

"When  once  a  person  is  thoroughly  under  the  influence  of 
the  habit,  a  cessation  of  the  use  of  the  drug  produces  symptoms, 
both  physical  and  mental,  of  such  intensity  that  few  are  strong 
enough  to  resist  the  craving  thus  produced  and,  unaided,  break  off 
the  habit.  When  the  effects  of  the  last  injection  begin  to  wear 
off,  restlessness,  malaise,  yawning,  and  sneezing  appear;  the 
craving  increases  and  can  only  be  entirely  relieved  by  a  further 
dose.  The  length  of  time,  after  the  last  dose,  at  which  these 
symptoms  will  begin  depends  on  the  individual.  Following 
quickly  on  the  malaise,  the  eyes  begin  to  water  and  the  eyelids 
droop.  The  eyes  lose  their  lustre  and  vision  is  much  disturbed. 
The  face  becomes  pale  and  an  expression  of  intense  distress  is 
very  noticeable.  Hearing  is  diminished  and  there  is  a  mental 
hebetude  which  prevents  all  intellectual  work.  There  is  a  trem- 
bling of  the  hands  and  of  the  arm  in  supination  and  pronation, 
varying  markedly  from  the  alcoholic  tremor.  In  this  condition 


404  Narcotic  Drug  Diseases  and  Allied  Ailments. 

there  is  nothing  that  morphinists  will  not  do,  and  no  means  that 
they  will  not  employ,  in  order  to  obtain  morphia.  As  enforced 
abstinence  continues,  the  patient  may  develop  epileptiform  at- 
tacks or  hysteria,  or  there  may  be,  in  neurotic  individuals,  a  state 
of  choreic  jactitation.  In  extreme  cases  a  form  of  mania  may 
develop  in  which  the  patients  pace  the  room,  shrieking,  crying, 
throwing  themselves  about,  using  whatever  instrument  comes  to 
hand  to  commit  suicide,  or  they  may  attack  their  attendants. 
Hallucinations  of  sight  and  hearing  may  develop  and  these  are 
always  of  a  terrifying  nature.  This  is  most  frequently  seen  in 
those  who  have  taken  alcohol  with  their  morphia,  but  it  not  in- 
frequently develops  in  those  who  have  taken  morphia  alone. 
Often,  before  these  mental  disturbances  are  fully  developed,  the 
patients  are  overcome  with  a  sensation  of  extreme  weakness  and 
forced  to  keep  in  bed.  They  are  pale  and  haggard;  there  is 
nausea  and  vomiting,  and  almost  invariably  a  diarrhea  develops, 
which  may  become  extremely  profuse.  This  is  often  accom- 
panied with  intense  abdominal  pain  and  hyperesthesia  of  the  skin, 
so  that  the  patient  can  scarcely  support  the  weight  of  the  bed- 
clothes; the  body  is  often  covered  with  a  cold  sweat,  and  there 
may  be  chills  of  great  intensity. 

"When  morphia  is  cut  off  abruptly  there  is  great  danger  of 
collapse.  This  may  supervene  on  the  second  or  third  day  and  the 
patient  shows  increased  weakness,  appears  pinched  and  haggard, 
while  the  pulse  becomes  small  and  then  disappears.  Or  he  may 
show  a  sudden  high  pulse  tension,  feebleness  of  the  heart  action, 
and  suddenly,  while  wandering  restlessly  around  the  room,  fall 
pulseless  to  the  floor.  Sometimes  the  fatal  collapse  may  occur 
without  warning  while  the  patient  is  quietly  talking  or  sitting  in 
bed.  Still  another  form  of  collapse  may  occur ;  the  face  becomes 
deep  red,  the  eyes  shine  brilliantly,  the  pulse  falls  to  40,  and  the 
patient  loses  consciousness  after  a  feeling  of  intense  agony. 
These  collapses  may  last  for  fifteen  or  twenty  minutes ;  they  may 
recur  three  or  four  times  in  the  twenty-four  hours,  and  the 


Obsolete  Ideas  as  to  Treatment.  405 

patient  may  recover  or  he  may  die  in  any  of  them  unless  morphia 
is  given.  Fortunately  these  attacks  are  rare  when  the  drug  is 
withdrawn  gradually,  but  they  are  fairly  common  when  this  is 
done  abruptly.  .  .  . 

"Treatment. — The  question  often  arises,  whether  the  patient 
should  be  sent  to  some  retreat,  or  whether  a  successful  issue  can 
be  followed  out  at  home.  If  the  home  treatment  is  decided  upon, 
the  family  must  be  made  to  realize  that  they  are  dealing  with  the 
most  cunning  and  cleverly  deceptive  kind  of  individual,  who  will 
stop  at  nothing,  and  who  is  probably  concealing  somewhere  a 
supply  of  morphia.  The  suffering  may  be  intense  and  will  cer- 
tainly be  intentionally  increased  in  order  to  obtain  sympathy  and 
to  break  off  the  treatment  whenever  it  is  possible.  ...  In 
retreats  or  hospitals,  the  sufferings  can  be  reduced  to  a  minimum 
and  when  it  is  possible  the  treatment  should  always  be  carried  on 
in  some  such  institution.  The  question  of  the  abrupt  withdrawal 
or  the  slow  method  always  comes  into  consideration.  Levinstein, 
who  used  the  abrupt  method,  says  that  he  does  not  believe  that 
this  should  be  done  unless  the  patient  is  otherwise  healthy  and 
suffering  only  from  the  symptoms  due  to  morphia.  This  in  itself 
shows  the  intensity  of  the  strain  and  suffering  that  the  abrupt 
method  induces,  and  the  danger  of  a  collapse,  which  may  be  fatal, 
is  most  apt  to  occur  in  this  method.  The  rapid  method,  by  which 
the  morphia  is  reduced  to  half  the  accustomed  dose  the  first  day 
and  then  half  the  next  day  and  so  in  a  few  days  is  entirely  with- 
drawn, is  practicable  in  the  majority  of  cases.  The  slow  method, 
by  which  the  drug  is  very  gradually  withdrawn,  is  useful  for  the 
very  weak  patients  or  those  who  suffer  from  some  chronic  dis- 
ease and  have  gradually  become  addicted  to  excessive  use.  But 
in  patients  who  are  not  afflicted  with  any  chronic  disease,  it  is 
apt  to  be  extremely  tedious  and  trying,  really  prolongs  the  suffer- 
ing, and  may  discourage  the  patient,  the  physician,  and  the  family. 

"The  best  method  in  the  majority  of  cases  is  to  endeavor  to 
find  approximately  how  much  morphia  the  patient  has  been 


406  Narcotic  Drug  Diseases  and  Allied  Ailments. 

accustomed  to  and  cut  it  at  least  in  half  and  give  this  amount  in 
divided  doses  for  the  first  twenty-four  hours.  .  .  .  The  best 
drug  to  equalize  the  circulation  and  to  reduce  the  physical  craving 
and  suffering  to  a  minimum  is  the  subcutaneous  use  of  Living- 
ston's solution  of  ergot  as  described  under  alcoholism.  To  allay 
the  nervousness,  warm  baths  are  often  very  efficacious.  Kane 
recommends  that  they  be  given  at  a  temperature  of  112°  F.,  and 
the  patient  rubbed  down  quickly,  placed  in  bed,  and  covered  up 
warmly.  To  combat  the  insomnia,  cold  packs  are  often  useful. 
A  tonic  of  nux  vomica  and  compound  tincture  of  cinchona  with 
capsicum,  given  three  or  four  times  a  day,  is  of  great  assistance. 
Often  in  the  first  few  days  champagne  or  sherry  is  helpful,  but 
this  should  not  be  prolonged,  for  these  patients  are  as  prone  to 
take  up  other  habits  as  they  were  originally  to  take  to  morphia. 
Chloral  as  a  hypnotic  has  been  condemned  by  most  writers. 
Levinstein  says  that  it  tends  to  increase  the  excitement.  Kane 
recommends  bromides,  given  in  large  amounts  of  water,  even  in 
i oo-gram  doses.  The  patient  should  be  fed  with  koumyss  and 
eggs  as  the  most  easily  assimilated  food."  .  .  . 

The  fact  that  so  eminent  a  man  as  Osier  selected 
Lambert  to  write  the  article  on  morphinism  for  his 
"Modern  Medicine"  is  an  announcement  to  the  profes- 
sion that  Lambert  is  regarded  as  a  man  competent  to 
speak  with  authority  on  that  subject.  It  is  doubtless 
true  that  Lambert  has  had  a  large  number  of  alcohol 
and  drug  patients  in  his  service,  and  that  this  afforded 
ample  opportunity  for  the  study  of  such  cases,  but 
Lambert's  writings  do  not  show  that  he  has  profited 
much  by  that  opportunity.  He  does  not  seem  to  have 
advanced  in  his  knowledge  as  to  the  real  nature  of  the 
condition,  the  pathology  of  the  drug  disease,  beyond  the 
position  generally  held  by  the  profession. 

He,  in  common  with  the  profession  generally,  holds 
that  morphinism  is  a  mere  vice,  and  that  the  dominating 


Craving  for  Narcotics,  a  "Straw  Man"  407 

factor  in  it,  the  essential  element  to  be  overcome  by  treat- 
ment, is  the  unnatural  craving  for  the  narcotic. 

This  straw  man,  this  unnatural  appetite  or  craving, 
supposedly  the  result  of  indulged  vice,  is  set  up,  and 
around  it  is  woven  a  mass  of  error  not  to  be  found  else- 
where in  medical  literature.  The  failure  to  acquire  and 
hold  clean-cut  ideas,  definite  knowledge,  as  to  the  pathol- 
ogy of  narcotic  addiction  has  left  the  profession  in  a 
most  vulnerable  position,  one  in  which  they  were  not 
only  not  able  to  combat  error,  but  in  which  they  were 
easily  misled  by  the  spacious  claims  of  anyone  who  had 
the  effrontery  to  announce  the  discovery  a  "cure,"  a 
"specific,"  for  drug  addiction. 

Lambert  is  no  exception  to  the  rule,  and  it  is  quite 
evident  to  all  who  have  had  extensive  experience  in  the 
treatment  of  patients  of  this  class  that  he  has  been 
"taken  in"  by  a  shrewd  layman  with  his  "specific"  and 
has  been  led,  erroneously,  to  proclaim  it  to  the  profession 
as  such. 

Lambert's  article  was  published  in  the  Journal  of 
the  American  Medical  Association  of  Sept.  25,  1909, 
under  the  title  "The  Obliteration  of  the  Craving  for 
Narcotics."  As  the  author  expects  to  point  out  a  number 
of  things  in  that  article  which  he  deems  erroneous  and 
which  are  calculated  to  lead  those  who  follow  its  teach- 
ing into  serious  complications,  he  thinks  it  best  to  repro- 
duce in  full  that  part  of  Lambert's  article  relating  to  the 
treatment  of  drug  cases.  It  is  as  follows : — 

"If  some  years  ago  anyone  had  told  me  that  it  was  possible 
to  take  away  the  desire  for  morphin,  cocain,  or  alcohol  in  less 
than  five  days  with  a  minimum  of  discomfort  and  suffering  to  the 
patient,  I  should  have  felt  justified  in  treating  the  statement  with 
a  polite  skepticism.  Such,  however,  is  the  fact,  if  the  treatment 
which  is  about  to  be  described  in  this  article  is  carefully  carried 


408  Narcotic  Drug  Diseases  and  Allied  Ailments. 

out.  I  do  not  doubt  that  in  my  turn  I  shall  be  met  with  skepti- 
cism, and  perhaps  ridicule,  and  more  especially  from  those 
members  of  the  profession  who  have  struggled  and  toiled  to  break 
up  the  morphin  and  cocain  habits.  Heretofore  there  has  been 
nothing  so  discouraging,  so  trying  to  both  physician  and  patient, 
as  the  endeavor  to  eradicate  the  craving  for  these  drugs. 

"In  my  service  in  the  alcoholic  wards  of  Bellevue  Hospital 
most  of  the  patients  were  simply  in  the  various  stages  and  degrees 
of  alcoholism,  but  there  was  always  about  I  per  cent,  among  the 
men  and  2  per  cent,  among  the  women  who  were  addicted  to 
morphin  and  cocain.  Many  of  these  patients  did  not  wish  to  be 
cured;  many  did  earnestly  desire  to  be  rid  of  their  enslaving 
habit.  Many  were  the  forms  of  treatment  and  drugs  with  which 
I  tried  to  break  off  the  habit  and  take  away  the  craving.  In  a 
very  few  cases  I  sometimes  believed  that  I  had  succeeded,  but 
even  in  these  cases  there  is  always  a  doubt  in  my  mind.  In  the 
vast  majority  of  patients  I  know  that  I  failed. 

"Five  years  ago  Mr.  Charles  B.  Towns,  of  New  York  City, 
informed  me  that  he  had  a  treatment  by  the  use  of  which  it  was 
possible  in  about  three  days  to  remove  the  craving  for  morphin 
and  cocain  and  also  for  alcohol.  After  this  desire  for  the  nar- 
cotics was  gone  the  patients  would  be  able  to  remain  free  from  the 
use  of  morphin,  and  if  it  was  worth  while  to  the  patients  it  is 
possible  for  them  to  abstain  from  the  use  of  cocain  and  alcohol. 
Mr.  Towns,  not  being  a  physician,  was  not  bound  to  tell  me  the 
ingredients  of  this  treatment.  I  begged  him  to  publish  it  and 
to  put  it  on  an  ethical  basis,  as  otherwise  I  could  not  use  it,  but 
at  that  time  it  did  not  seem  expedient  for  him  to  do  so.  Recently 
he  has  made  the  treatment  known  in  all  its  details  to  the  Opium 
Congress  at  Shanghai,  and  on  his  return  from  China  he  has  given 
me  the  full  details  of  the  treatment  and  I  have  been  using  it  in 
Bellevue  Hospital  during  the  last  two  months. 

"While  the  treatment  was  still  unknown  to  me,  and  before  I 
used  it,  I  watched  Mr.  Towns  treat  various  persons  addicted  to 


A    Shrewd  Layman's  Hypnotic   Influence.  409 

morphin,  cocain  and  alcohol,  and  found  that  the  claims  that  he 
made  for  the  treatment  were  true.  I  have,  therefore,  watched 
patients  who  ceased  the  use  of  their  drug  five  years  ago  and  have 
not  returned  to  it,  and  recently  I  have  myself  carried  out  the 
treatment  indicated  below. 

"There  are  so  many  factors  to  be  considered  in  treating 
those  addicted  to  narcotic  drugs  that  there  is  no  intention  here 
to  claim  an  infallible  cure.  We  are  dealing  very  often  with  the 
morally  perverted,  with  those  who  have  been  suffering  mental  and 
physical  pain,  with  those  who  have  endeavored  to  stimulate  their 
flagging  abilities  to  ward  off  failure  in  life  and  to  spur  themselves 
on  by  means  of  these  drugs  in  the  hope  of  succeeding  where 
failure  seemed  inevitable.  Every  morphin  habitue  knows  the 
ease  and  sureness  with  which  morphin  will  relieve  pain  and  dis- 
tress, and  if  once  off  the  drug  and  the  temptation  returns  there  is 
a  full  knowledge  of  how  it  may  all  be  relieved.  There  is  no 
stimulant  like  cocain,  which  so  fully  gives  the  feeling  of  being 
able  to  do  all  that  one  hopes  and  dreams  possible ;  and  there  is  no 
drug  which  so  gives  the  feeling  of  physical  and  mental  well-being. 
Added  to  this,  after  a  few  months'  use  of  cocain  there  arises  a 
form  of  persecutory  insanity,  which  convinces  those  addicted  to 
the  drug  that  every  one  in  all  the  world  is  against  them,  and  they 
refuse  to  listen  to  any  advice.  Most  alcoholics  do  not  desire  to 
cease  from  their  drinking.  When  once  the  habit  becomes  thor- 
oughly formed  they  do  not  become  drunk  from  Haphazard  drink- 
ing, but  they  deliberately  drink  to  excess  that  they  may  blunt  the 
knowledge  of  their  unhappiness  and  the  realization  of  their 
misery  and  their  environment.  Alcohol  also  in  many  cases  brings 
with  it  actual  physical  lesions  in  the  nervous  tissues,  so  that  with 
a  deteriorated  mentality  the  higher  functions  of  the  mind  are 
destroyed. 

"The  specific  in  this  treatment  is  the  old  15  per  cent,  tincture 
of  belladonna  and  the  fluid  extract  of  xanthoxylum  (of  prickly 
ash)  and  the  fluid  extract  of  hyoscyamus  mixed  in  the  following 
proportions : — 


410  Narcotic  Drug  Diseases  and  Allied  Ailments. 

Gm.  or  c.c. 

IJ  Tincturse  belladonnas    62        Sij. 

Fluidextracti  xanthoxyli, 

Fluidextracti  hyoscyami    §331        3j. 

"While  this  specific  is  being  given,  the  patients  do  not  suffer 
from  the  intense  diarrhea  which  usually  accompanies  the  with- 
drawal of  morphin.  On  the  contrary,  the  most  energetic,  drastic 
cathartic  medication  is  necessary  to  obtain  the  desired  elimination 
and  to  make  their  bowels  move  satisfactorily.  This  cathartic 
medication  forms  one  of  the  crucial  points  in  the  treatment. 
Unless  it  is  properly  carried  out  the  treatment  will  fail  and  the 
patient  suffer  intensely  and  to  no  avail.  If  properly  carried  out, 
according  to  the  directions  given  below,  the  sufferings  of  the 
patient  are  actually  but  little,  and  the  treatment  goes  on  to  a 
successful  issue. 

"The  most  useful  combinations  in  my  hands  have  been  the 
compound  cathartic  pills  of  the  pharmacopeia,  which  contain : — 

Gm.  or  c.c. 

Ifc  Extracti  colocynthidis  compositi    0.08  gr.  }%. 

Hydrargyri  chloridi  mitis  0.06  gr.  j. 

Cambogise   0.016  gr.  54- 

Resinae  jalapse  0.02  gr.  %. 

"And  also  the  pilulae  catharticse  vegetabilis : — 

Gm.  or  c.c. 

IJ.  Extracti  colocynthidis  compositi  0.06          gr.  j. 

Extracti  hyoscyami, 

Extracti  jalapae    aa  0.03          gr.  ss. 

Extracti  leptandrse, 

Extracti  resinae    podophylli    aa  0.015        Sf-  *A' 

Olei  menthse  piperitae  0.008         v\  l/%. 

"To  these  last  I  have  added  in  each  pill  yw  grain  (6  mg.) 
of  the  oleoresin  of  capsicum,  %  grain  (30  mg.)  of  ginger,  and 
y25  minim  (0.0025  c.c.)  of  croton  oil.  I  also  found  that  the 
ordinary  stock  preparations  of  compound  cathartic  pills  were  too 
dry  to  be  effective.  I,  therefore,  had  made  up  fresh  masses  of 
these  preparations  and  the  mass  equivalent  to  each  pill  put  into 
a  capsule.  The  preparations  kept  their  freshness  and  their  ef- 


A  Specific  Not  a  Specific.  411 

fectiveness  was  very  noticeably  increased.  I  also  had  put  in 
capsules  blue  mass  in  5-grain  doses.  I  have  thus  gone  into  details 
because  of  their  importance. 

"For  brevity,  I  shall  hereafter  refer  to  the  compound  cathartic 
pills  as  C.C.  pills,  and  the  vegetable  cathartic  pills,  as  modified 
above,  as  B.B.  pills. 

''The  treatment  in  a  case  of  morphin  or  cocain  is  as  follows : 
Before  beginning  the  treatment,  give  four  C.C.  pills  and  5  grains 
of  blue  mass.  It  is  also  wise  at  this  time  to  give  an  enema  of 
soapsuds  to  clean  out  the  rectum  and  sigmoid,  thoroughly.  When 
these  pills  have  begun  to  act,  begin  with  the  specific,  6  to  8  minims, 
and  give  it  every  hour  throughout  the  treatment,  or  until  some 
signs  of  belladonna  intoxication  are  observed.  Every  six  hours, 
increase  the  specific  2  minims  until  14  or  16  minims  are  being 
taken  every  hour.  Do  not  increase  above  16  minims.  If  the 
signs  of  belladonna  intoxication  are  noticed,  such  as  dilated 
pupils,  dryness  of  the  throat,  red  rash,  or  a  rapidity  and  incisive- 
ness  of  speech,  or  sometimes  a  beginning  delirium,  stop  the 
specific.  When  these  belladonna  symptoms  have  subsided  begin 
the  specific  again  in  8-minim  doses.  Some  patients  are  very 
susceptible  to  belladonna  and  one  may  have  to  begin  again  with 
4,  5,  or  6  minims.  Give  with  the  first  dose  of  the  specific  from 
one-half  to  two-thirds  of  the  usual  total  daily  dose  of  opium, 
morphin,  or  cocain  which  the  patient  is  taking  at  the  time  of  his 
treatment.  Divide  this  amount  of  narcotic  in  three  doses  and 
give  them  at  half-hour  intervals  by  mouth  or  by  hypodermic  as 
the  patient  is  accustomed  to  take  it.  After  the  first  dose  of  the 
specific,  wait  fourteen  hours  and  give  four  C.C.  pills  and  5  grains 
of  blue  mass ;  again,  six  hours  later,  repeat  the  four  C.C.  pills,  or 
give  four  to  six  B.B.  pills.  It  is  essential  that  the  cathartic  should 
act  at  this  time,  and,  if  the  above  amounts  do  not  produce  the 
desired  action  within  three  or  four  hours,  they  must  be  repeated 
with  5  to  10  grains  of  blue  mass.  It  is  astonishing  how  difficult 
it  sometimes  is  to  obtain  a  cathartic  action  at  this  period,  but 


412  Narcotic  Drug  Diseases  and  Allied  Ailments. 

cathartics  must  be  persisted  in  until  a  movement  is  obtained.  If 
this  is  not  done,  the  patients  are  liable  to  begin  to  vomit,  and  the 
distressing  symptoms  of  the  narcotic  withdrawal  will  come  out  in 
full  force.  An  ox-gall  enema  is  sometimes  of  assistance. 

"After  the  bowels  have  acted,  but  not  before,  one-third  or 
one-half  the  original  dose  of  the  narcotic  may  be  given.  This 
will  make  the  patient  comfortable  and  contented  and  ready  for 
the  final  stage. 

"Twelve  hours  after  the  second  dose  of  the  narcotic  again 
give  four  C.C.  pills  or  four  to  six  B.B.  pills  with  5  grains  of  blue 
mass,  and  six  hours  later  give  an  ounce  or  more  of  castor-oil 
disguised  in  coffee  or  orange  juice,  but  not  in  whiskey.  Just 
before  the  castor-oil  acts,  one  may  have  to  give  from  2  to  5  grains 
of  codein  phosphate  hypodermically  or  by  mouth  to  quiet  the 
nervousness  and  discomfort.  This  is  not  always  necessary,  but 
it  adds  to  the  comfort  of  the  patient  and  does  not  tie  up  the 
secretion  as  does  opium  or  morphin.  The  castor-oil  at  this  time 
will  produce  a  characteristic  stool,  which  shows  that  the  entire 
treatment  may  cease.  This  is  a  liquid  green  stool,  composed  of 
mucus  and  bile.  When  this  stool  occurs,  or  shortly  after,  the 
patients  often  will  feel  suddenly  relaxed  and  comfortable,  and 
their  previous  discomfort  ceases.  The  transition  from  discomfort 
to  relaxation  and  contentment  is  often  strikingly  marked. 

"After  the  patient  has  been  under  treatment  for  thirty  hours 
one  should  begin  to  give  some  cardiac  stimulant,  such  as  strych- 
nin, y3Q  to  YQQ  grain  every  three  hours,  or  digitalis,  or  strophan- 
thus,  either  one  of  these  separately  or  in  combination.  These 
tend  to  overcome  the  relaxation  of  the  vascular  system,  which  in 
these  patients  often  produces  a  feeling  of  exhaustion. 

"During  the  treatment  the  patients  should  be  given  a  regular 
diet  of  easily  digested  foods,  such  as  eggs,  cereals,  bread  and 
butter,  and  vegetables;  coffee  or  tea  if  they  desire  it.  Many  of 
these  patients  have  a  good  appetite  throughout  and  eat  abun- 
dantly ;  some,  of  course,  do  not,  and,  beginning  in  a  poor  physical 


Exhaustive  Purgation.  413 

condition,  do  not  begin  to  eat  abundantly  until  after  the  treatment 
is  ended.  After  they  are  through  the  treatment,  their  appetite 
becomes  voracious,  and  during  the  first  week  care  must  be  taken 
that  they  do  not  overeat,  which  they  are  very  prone  to  do.  If 
their  stomachs  should  become  overloaded  the  discomfort  will 
often  make  them  feel  as  if  they  were  suffering  from  the  symptoms 
of  withdrawal  of  their  accustomed  narcotic.  If  this  occurs,  the 
best  thing  to  do  is  to  give  them  an  emetic,  and  their  distressing 
symptoms  will  soon  cease. 

"In  the  above  description  of  treatment  for  morphin,  cocain, 
or  alcohol,  I  have  spoken  as  if  the  patient  was  taking  a  single 
drug.  Very  frequently  we  encounter  patients  who  are  taking 
morphin  and  cocain  or  morphin  and  alcohol.  When  this  treat- 
ment is  given  to  the  cocain  habitue  who  is  taking  only  cocain, 
or  when  morphin  and  cocain  are  combined  the  patients  sleep 
almost  continuously  throughout  the  treatment.  Cocain  is  usually 
taken  as  a  stimulant,  an  antidote  against  the  depressing  effects 
of  the  morphin,  and  this  should  never  be  forgotten;  therefore, 
the  initial  dose  of  the  morphin  in  the  very  beginning  of  the  treat- 
ment, when  the  two  drugs  are  combined,  should  be  smaller  than 
when  morphin  alone  is  taken.  Cocain  is  so  strong  a  stimulant 
that  when  it  is  withdrawn  it  is  often  necessary,  from  the  very 
beginning  of  the  treatment,  to  give  a  stimulant,  such  as  strychnin, 
instead  of  waiting  thirty  hours,  as  stated  above. 

"The  familiar  symptoms  in  morphin  withdrawal,  such  as 
intense  diarrhea,  intense  joint  and  abdominal  pains,  and  muscular 
contractions,  do  not  occur  when  this  treatment  is  properly  carried 
out.  They  are  most  likely  to  appear  just  before  the  second 
cathartic  acts,  and  for  that  reason,  as  emphasized  above,  the 
cathartic  action  must  be  obtained  at  this  time.  If  this  is  not 
done,  the  patients  are  certain  to  have  trouble. 

"The  accompanying  table  gives  in  abbreviated  form  the 
course  of  the  treatment  in  a  number  of  patients  and  gives  a 
statistical  view  of  the  various  types  of  patients  and  the  duration 


414  Narcotic  Drug  Diseases  and  Allied  Ailments. 

of  their  treatment.  The  duration  of  stay  in  the  hospital  may 
seem  excessively  long,  but  many  patients  remain  in  order  that 
they  might  be  built  up  physically  after  their  treatment.  Their 
craving  for  their  drug  ceased  when  the  characteristic  stool  oc- 
curred. 

"As  is  well  known,  morphin  is  often  taken  to  smother  the 
pain  of  some  underlying  disease,  or  the  distress  of  some  disturb- 
ance of  function.  If  these  causes  still  exist  after  the  morphin 
has  been  eliminated,  the  evidence  of  this  former  disease,  or  this 
disturbed  function  will  come  to  the  surface  again.  At  times  the 
narcotic  addiction  is  but  a  symptom  of  some  abnormal  mental 
state,  which  is  only  diagnosticated  after  the  narcotic  craving  in  the 
patient  has  been  removed.  This  treatment  is  not  a  cure-all  for 
disease,  a  rehabilitator  of  all  the  disturbed  functions  of  the  body, 
but  if  properly  carried  out  it  will  obliterate  the  craving  for 
the  narcotic  and  the  patient  starts  anew  where  he  was  before 
taking  the  narcotic. 

"The  details  of  this  treatment  have  been  given  so  minutely 
because  it  is  necessary  that  they  should  be  carried  out,  for  the 
success  of  this  treatment  depends  on  the  conscientious  adherence 
to  its  many  details.  Unless  the  adherence  is  given  this  treatment 
will  probably  not  succeed.  A  successful  issue  is  endangered  when 
an  attempt  is  made  to  carry  out  the  treatment  in  the  patients' 
homes  and  in  their  accustomed  environment.  They  must  be 
placed  where  they  are  alone  and  where  they  can  be  carefully 
watched.  Morphin  habitues  never  begin  a  treatment  with  any 
confidence  of  its  success,  but  invariably  with  a  dread  of  the  dis- 
tressing withdrawal  symptoms.  They  will  secrete  the  drug  in  the 
most  unexpected  places,  and  they  are  the  most  sly  and  resourceful 
creatures  on  earth,  especially  those  who  have  ever  tried  to  break 
it  off.  No  physician  is  capable  of  taking  this  treatment  himself 
and  carrying  it  through  successfully.  If  it  is  attempted,  the  old 
medical  adage  that  the  doctor  who  treats  himself  has  a  fool  for 
a  patient  will  be  strikingly  exemplified. 


Physician  Cannot  Trust  Himself.  415 

"This  treatment  does  not  offer  a  cure  of  the  perverted  habits 
of  the  human  race,  or  a  regeneration  of  the  mentally  defective. 
It  will  obliterate  the  craving  for  narcotic  drugs,  and  that  is  all 
that  is  claimed  for  it." 

The  table  referred  to  in  the  above  article  gives  the 
details  of  the  treatment  of  28  cases  of  narcotic  addiction. 
Two  of  these  were  addicted  to  morphine  and  cocaine,  24 
to  morphine  alone,  I  to  heroin,  and  i  to  laudanum.  In 
this  series  there  were  17  males  and  n  females;  the 
average  age  was  36  years;  the  average  duration  of  ad- 
diction was  four  and  two-thirds  years ;  the  average  daily 
dose  was  9.6  grains  of  morphine;  the  average  duration 
of  the  so-called  "specific"  medication  was  sixty  hours; 
the  average  length  of  time  from  the  last  dose  of  the 
opiate  to  the  last  dose  of  the  belladonna  mixture  was 
sixteen  and  one-half  hours. 

The  average  length  of  time  spent  in  the  hospital  by 
each  patient  was  eleven  days.  Four  were  discharged 
within  the  first  week,  I  each  on  the  fourth,  fifth,  sixth, 
and  seventh  day.  Twenty-one  were  discharged  during 
the  second  week,  2  each  on  the  eighth,  ninth,  and  tenth 
day,  and  4  each  on  the  eleventh,  twelfth,  and  thirteenth 
day,  and  3  on  the  fourteenth  day.  Of  the  remaining  3, 
i  was  discharged  on  the  seventeenth  day,  I  on  the 
twenty-second  day,  and  i  on  the  twenty-sixth  day. 
Both  of  the  cases  treated  for  morphine-cocaine  habit 
were  discharged  on  the  eighth  day. 

AUTHOR'S  COMMENT. 

The  members  of  the  profession  at  large  are  practi- 
cally without  experience  in  the  treatment  and  manage- 
ment of  narcotic  drug  patients.  The  teachings  of  the 
authorities  have  not  been  based  upon  sound  pathological 


416  Narcotic  Drug  Diseases  and  'Allied  Ailments. 

and  physiological  principles;  therefore,  members  of  the 
profession  are  not  in  position  to  read  literature  on  that 
subject  with  the  same  critical  discrimination  with  which 
they  read  literature  on  other  medical  subjects. 

This  state  of  affairs  would  naturally  lead  them  to 
accept  without  question  the  teachings  of  anyone  who  is 
regarded  as  an  authority  on  this  subject,  and  this  makes 
the  teachings  of  such  a  one.  when  erroneous,  extremely 
hurtful. 

A  careful  reading  of  the  writings  of  Lambert  by  one 
whose  experience  is  such  as  to  justify  him  in  passing  a 
critical  judgment  upon  them  reveals  errors  of  such 
gravity  that  the  author  deems  it  his  duty  to  call  at- 
tention to  some  of  them. 

An  unfortunate  feature  of  Lambert's  last-quoted 
article  is  that  it  appears  to  be  based  upon  no  definite  un- 
derstanding of  what  he  sets  out  to  treat,  leaving  it, 
indeed,  in  doubt  as  to  whether  he  recognized  any  pa- 
thology whatever  as  being  involved.  We  can  only  get 
light  as  to  the  doctor's  views  on  this  subject  by  reference 
to  his  other  writings. 

In  his  article  in  Osier's  "Modern  Medicine,"  he 
describes  addiction  as  a  vice  and  seems  to  follow  the 
time-honored  custom  of  regarding  the  pathology  as  nil. 
One  reading  his  article  of  September,  1909,  would  almost 
be  led  to  the  conclusion  that  he  had  changed  his  views  on 
that  question,  but  that  is  evidently  not  the  case,  since  in 
an  article  published  in  the  Journal  of  the  American 
Medical  Association,  February  18,  1911,  he  says: 
"Alcoholism  is  a  social  vice  and  not  a  secret  one,  as  is 
morphinism." 

Now,  if,  indeed,  morphinism  be  a  vice,  no  more,  no 
less,  we  are  at  a  loss  to  imagine  how  the  doctor  can 
regard  his  belladonna  compound  as  a  "specific"  for 


Lambert  Considers  Morphinism  a  Vice.  417 

moral  obliquity,  or  how  he  can  connect  the  appearance 
of  biliverdin  in  the  stools  with  the  disappearance  of  a 
vice.  "Purge  me  with  hyssop,  etc.,"  is  inspired  scrip- 
ture, but  so  far  as  we  know  it  has  yet  to  gain  a  reputa- 
tion for  saving  grace  in  modern  therapeutics,  rationally 
applied. 

So  the  doctor  goes  out  with  his  belladonna  "specific" 
and  with  his  purgative  compound  to  combat  a  vice  and 
claims  to  the  profession  that  he  succeeds  in  dosing  and 
purging  the  "very  devil"  out  of  his  patients,  but  his 
system  seems  to  be  at  conflict  with  itself,  and  he  appears 
to  be  as  uncertain  as  to  which  of  the  medicines  he  ad- 
ministers does  the  work  as  to  what  he  is  treating  and 
why. 

He  evidently  regards  the  "craving  for  the  drug"  as 
the  principal  element  of  the  addiction  and  the  one  most 
difficult  to  be  overcome  by  treatment.  He  brings  his 
belladonna  compound  forward  as  a  "specific"  which 
obliterates  this  craving  in  a  few  days'  time,  yet  he  says, 
"This  cathartic  medication  forms  one  of  the  crucial 
points  in  the  treatment.  Unless  it  is  properly  carried 
out,  the  treatment  will  fail  and  the  patient  suffer  in- 
tensely and  to  no  avail."  The  author  would  ask,  Which 
is  the  real  curative  agent?  The  purgative  or  the 
"specific"?  Why  call  a  compound  a  "specific"  when  it 
will  not  cure  ? 

The  word  "specific"  when  used  in  medicine  and  ap- 
plied to  a  remedy  has  a  well-defined,  clean-cut  meaning. 
It  is  only  applied  to  remedies  which  of  themselves  and 
unaided  have  the  power  to  effect  a  cure,  such,  for 
example,  as  mercury  in  syphilis,  quinine  in  malaria.  It  is 
evident  that  the  doctor's  article  is  misleading  on  this 
point. 


27 


418  Narcotic  Drug  Diseases  and  Allied  Ailments. 

From  the  standpoint  of  a  practical  therapeutist,  the 
teachings  of  this  writer  are  open  to  far  more  serious 
objections  than  the  one  just  mentioned. 

Lambert  well  urges  the  necessity  for  free  purgation, 
but  the  purgative  compounds  he  recommends  are  ex- 
tremely drastic  and  the  extent  to  which  they  are  admin- 
istered places  an  unnecessary  tax  on  the  strength  of  the 
patient.  Drug  habitues,  as  a  rule,  are  very  anemic ;  their 
blood  is  thin;  their  tissues  are  poorly  nourished;  they 
have  no  strength  to  spare ;  therefore,  in  preparing  them 
for  the  withdrawal  of  their  drug,  or  in  treating  them 
subsequent  to  it,  the  most  scrupulous  care  should  be  ex- 
ercised to  preserve  their  strength.  While  the  admin- 
istration of  purgatives  is  essential  in  any  effort  to  free 
the  system  of  toxic  matter,  these  should  be  selected  and 
compounded  so  as  to  act  in  the  most  conservative 
manner,  and  to  place  the  least  tax  on  the  resources  of 
the  system.  No  purgative  compound  which  depends 
on  reflex  action  to  excite  the  motor  function  of  the  bowel, 
as  do  those  recommended  by  Lambert,  meets  this  re- 
quirement. 

Lambert  finds  great  difficulty  in  getting  purgatives 
to  act.  This  is  true  because,  in  drug  habitues,  the  motor 
function  of  the  bowel  is  more  completely  suspended  than 
the  secretory  function  of  the  glands. 

In  order  to  secure  evacuation  of  the  intestinal  con- 
tents it  is  equally  as  necessary  to  stimulate  the  motor 
function  of  the  bowel  as  the  secretory  function  of  the 
intestinal  glands. 

Notwithstanding  this  fundamental  proposition,  Lam- 
bert administers  glandular  stimulants  and  trusts  to  their 
irritating  qualities,  or  to  the  irritating  qualities  of  the 
secretion  they  induce,  to  excite  peristalsis,  the  other 
essential  condition  to  bowel  movement.  When  the 


Principles  of  Purgation.  419 

nerve-centers  are  profoundly  impressed  with  narcotics, 
as  in  the  case  of  drug  habitues,  reflex  action  alone  is  not 
capable  of  exciting  efficient  peristalsis  unless  such  reflex 
action  is  induced  to  an  exaggerated  degree.  If  gland- 
ular stimulants  are  given  in  such  quantities  and  of  such 
an  irritating  quality  as  to  excite  this  exaggerated  degree 
of  reflex  action,  they  cause  much  distress,  colic,  griping, 
nausea,  etc.,  and  when  they  do  finally  act  they  act  with 
undue  severity  and  exhaust  the  strength  of  the  patient. 
On  the  other  hand,  if  the  motor  function  of  the  bowel  is 
induced  by  direct  stimulation  of  the  motor  centers,  then 
much  less  of  the  glandular  stimulant  is  required;  it  acts 
more  promptly  and  efficiently  and  with  much  less  tax 
on  the  resources  of  the  patient. 

There  is  no  question  but  that  the  emunctories  should 
be  thoroughly  aroused  and  free  purgation  obtained,  but 
any  course  of  treatment  which  involves  the  giving  of 
purgatives  equivalent  to  30  or  more  compound  cathartic 
pills  in  less  than  three  days'  time,  as  does  the  plan  ad- 
vocated by  Lambert,  is  extremely  drastic,  and,  in  the 
author's  opinion,  involves  an  unnecessary  waste  of  the 
patient's  strength.  Better  results  can  be  obtained  with 
far  more  conservative  measures. 

Strychnine  in  sufficient  quantities  to  overcome  the 
semiparalyzed  condition  of  the  intestine  and  to  excite 
active  peristalsis,  is  an  essential  ingredient  of  any  purga- 
tive compound  intended  to  empty  the  intestinal  canal  of  a 
drug  habitue,  if  that  is  to  be  accomplished  without  undue 
waste  of  the  patient's  strength.  The  administration  of 
glandular  stimulants  (chemical  irritants)  to  a  drug 
habitue  in  such  large  quantities  as  to  bring  about  a 
degree  of  irritation,  in  the  upper  part  of  the  intestinal 
canal,  sufficient  to  excite  efficient  peristalsis  by  reflex 
action,  is  as  unreasonable  as  the  effects  are  unpleasant 
and  exhausting. 


420  Narcotic  Drug  Diseases  and  Allied  Ailments. 

With  reference  to  the  obliteration  of  the  craving  for 
the  narcotic  about  which  Lambert  and  others  have  ex- 
pressed so  much  concern,  the  author  wishes  to  say  that 
the  demand  of  the  system  of  the  drug  habitue  for  his 
drug,  his  inclination  to  take  it,  his  desire  for  repeated 
doses  of  his  particular  drug,  springs  from  a  physical 
condition  and  not  from  a  mere  appetite  such  as  the  word 
craving  would  ordinarily  be  understood  to  imply. 

The  habitual  use  of  the  drug  brings  about  marked 
functional  derangement  of  every  organ  in  the  body. 
The  bowels  are  habitually  constipated,  the  portal  system 
is  engorged,  the  heart  is  overworked,  the  motor  function 
of  the  bowel  is  greatly  impaired,  the  activity  of  all  the 
secreting  and  excreting  organs  is  diminished,  the  body 
is  poorly  nourished,  and  the  entire  system  is  saturated 
with  the  products  of  tissue  disintegration;  in  fact,  an 
intense  toxemia  exists.  The  nervous  system  is  made  to 
tolerate  the  presence  of  this  toxic  matter  by  keeping  it 
constantly  blunted  by  the  effects  of  the  narcotic. 

The  urgent  demand  for  the  repetition  of  the  dose, 
the  so-called  craving,  is  due  mainly  to  the  effects  of  this 
toxic  matter  on  the  nervous  system.  If  this  toxic  matter 
is  removed  from  the  system,  and,  just  in  proportion  as 
it  is  done,  the  demand  for  the  narcotic  ceases,  the  so- 
called  craving  disappears,  without  the  intervention  or 
aid  of  any  "specific"  remedy. 

That  a  remedy  of  the  belladonna  group  does  meet 
one  of  the  indications  in  the  treatment  of  narcotic  cases 
is  unquestionably  true,  as  the  author  has  shown  in 
previous  chapters  of  this  work,  but  that  it  is  the  prin- 
cipal curative  agent  or  even  the  chief  factor  in  over- 
coming the  so-called  craving  he  denies. 

It  is  easily  capable  of  demonstration  that  the  toxic 
matter  in  the  system  of  the  drug  habitue  is  the  source  of 


Uncertainty  from  Galenic  Preparations.  421 

the  demand  for  repeated  doses  of  his  drug;  in  fact,  is 
the  essential  pathology  of  the  addiction.  When  this 
pathology  is  overcome,  when  the  system  is  freed  from 
the  toxic  matter,  the  craving  or  demand  for  the  drug 
disappears  as  soon  as  the  secondary  effects  of  the  opiate 
are  exhausted  without  further  treatment  of  any  kind. 

As  to  the  composition  and  mode  of  administration 
of  Lambert's  so-called  "specific"  the  author  wishes  to 
say  that  the  prickly  ash  in  the  quantities  given  in  the  dose 
of  the  "specific"  has  no  perceptible  effect  on  the  patient ; 
therefore,  it  had  as  well  be  left  out.  The  effects  of  the 
other  two  remedies,  belladonna  and  hyoscyamus,  are 
practically  the  same,  and  either  will  do  for  the  patient 
all  that  the  two  will  do  in  combination,  but  if  it  is  de- 
sired to  combine  them  there  can  be  no  objection;  how- 
ever, since  alkaloids  of  each  of  these  remedies  are  ob- 
tainable, the  author  does  not  deem  it  in  accord  with  the 
demands  of  rational  therapeutics  to  depend  upon  the 
stomach  administration  of  the  Galenic  preparations. 

The  strength  of  tinctures  and  fluidextracts  found  on 
the  market  varies  greatly,  sometimes  as  much  as  100 
per  cent. ;  therefore,  their  use,  because  of  this  variability 
of  strength,  introduces  an  element  of  uncertainty  which 
should  not  be  allowed  to  enter  into  so  important  an 
undertaking. 

Again,  the  stomach  is  often  much  disordered  and  the 
remedies  are  likely  to  be  rejected  by  vomiting,  but,  even 
if  they  are  not  vomited,  the  mucous  membrane  of  the 
stomach  is  so  irritated,  especially  if  purgative  com- 
pounds such  as  are  recommended  by  Lambert,  contain- 
ing colocynth,  gamboge,  podophyllin,  and  croton  oil,  are 
given,  that  the  absorption  of  remedies  is  interfered  with 
and  may  be  delayed  for  hours  at  a  time,  during  which 
the  patient  suffers  unnecessarily,  when  he  could  have 


422  Narcotic  Drug  Diseases  and  Allied  Ailments. 

been  relieved  promptly,  by  the  very  remedies  which  were 
being  given,  had  they  been  administered  hypodermically. 

Not  only  may  this  disordered  condition  of  the 
mucous  membrane  of  the  stomach  delay  the  absorption 
of  the  remedies  and  cause  the  patient  to  suffer  unneces- 
sarily, but  the  absorption  may  be  delayed  until  a  number 
of  doses  have  accumulated  in  the  stomach,  and  then, 
when  absorption  does  begin,  all  these  may  be  taken  up 
at  once,  with  the  result  that  the  patient  is  brought  more 
profoundly  under  the  influence  of  the  remedies  than  was 
intended,  or  than  is  desirable. 

The  author  insists  that  these  elements  of  uncer- 
tainty should  not  be  allowed  to  enter  into  an  under- 
taking of  this  kind,  especially  since  it  can  be  so  easily 
avoided  by  the  hypodermic  administration  of  the  active 
principles  of  these  remedies.  All  unnecessary  suffering 
should  be  avoided.  Suffering  impairs  the  vital  forces 
and  renders  recovery  less  certain. 

It  will  be  noticed  by  reference  to  the  abstract  of  the 
tabulated  report  of  the  28  cases  recorded  by  Lambert 
that  25  of  the  patients  were  discharged  from  the  hospital 
within  two  weeks  from  the  beginning  of  the  treatment. 
The  article  would  lead  anyone  to  believe  that  they  were 
cured  of  their  addiction  and  in  condition  to  think  and  act 
for  themselves  and  to  fully  regain  their  health  without 
further  treatment  or  supervision  from  anyone.  The 
author's  experience  will  not  allow  him  to  believe  that. 
He  feels  quite  sure  that  all  of  the  four  who  were  dis- 
charged during  the  first  week  returned  to  the  use  of 
some  stimulant  within  three  days  from  the  time  they  left 
the  hospital,  and  it  is  more  than  likely  that  the  same  is 
true  of  a  majority  of  those  who  were  discharged  during 
the  second  week. 

No  matter  how  perfectly  the  system  of  the  patient 
may  be  cleansed  from  toxic  matter  and  how  completely 


Too  Early  Discharge  of  Patients.  423 

the  "craving"  may  be  "obliterated,"  it  is  extremely  rare 
that  a  patient  of  this  class  can  be  brought  to  such  a 
condition  as  to  be  safely  trusted  to  think  and  act  for 
himself  within  ten  days  from  the  beginning  of  the  treat- 
ment. Time,  as  well  as  treatment,  is  an  essential  factor 
in  restoring  them  to  self-control,  and  they  should  not  be 
left  to  their  own  volition  until  they  have  so  completely 
regained  their  footing  as  not  only  to  make  it  "possible" 
for  them  to  refrain  from  taking  a  drug,  but  to  make  it 
certain  that  they  will  do  so. 

The  profession  expects  better  things  of  men  engaged 
in  the  treatment  of  narcotic  drug  cases  than  for  them  to 
merely  take  such  patients,  give  them  a  few  days' 
"specific"  treatment,  keep  them  a  few  days  longer,  and 
then  discharge  them  as  cured,  when,  in  fact,  they  have 
not  in  any  wise  regained  a  normal  condition.  Four 
weeks  from  the  beginning  of  treatment  is  quite  early 
enough  under  the  most  favorable  circumstances  for  any 
drug  patient  to  be  thrown  on  his  own  resources,  and  it 
would  be  far  better  if  he  could  be  under  the  personal 
supervision  of  his  physician  for  three  months. 

RECAPITULATION. 

In  recapitulation,  the  author's  objection  to  the  teach- 
ings of  Lambert  may  be  stated  as  follows : — 

Absence  of  definite  statement  as  to  the  pathology  of 
condition  considered. 

Erroneously  classifying  the  same  as  vice. 

Overestimation  of  the  importance  of  the  so-called 
craving. 

So-called  "specific"  not  a  specific. 

Failure  to  provide  for  physiological  stimulation  of 
the  motor  function  of  the  bowel,  an  essential  to  bowel 
movement. 


424  Narcotic  Drug  Diseases  and  Allied  Ailments. 

The  excessive  use  of  secretory  stimulants  of  an  un- 
necessarily drastic  type. 

Subjecting  the  patient  to  uncertainty  of  relief  from 
suffering,  and  to  the  overeffects  of  the  remedies,  by 
reason  of  the  varying  strength  of  the  Galenic  prepara- 
tions and  of  the  disordered  condition  of  the  stomach. 

At  least  25  of  the  28  patients  reported  in  the  series 
of  Lambert  were  discharged  from  the  hospital  too  early 
to  be  considered  cured. 


CHAPTER  XXII. 

THE  COCAINE  HABIT. 

IT  will  be  noticed  that  the  author  here  uses  the  word 
"habit,"  instead  of  disease.  This  is  done  advisedly ;  that 
is  to  say,  the  word  "habit,"  as  commonly  understood,  can 
be  properly  applied  to  the  habitual  use  of  cocaine,  but 
it  should  not  be  used  to  signify  the  conditions  growing 
out  of  the  prolonged  use  of  opiates. 

There  is  a  wide  difference  between  the  morphine  dis- 
ease, and  the  cocaine  habit.  The  morphine  disease  may 
be  acquired  justifiably ;  that  is,  because  of  the  legitimate 
use  of  morphine  for  relief  of  pain,  or,  inadvertently,  by 
using  it  for  support  during  excessively  long  working 
hours,  or  by  one  taking  it  in  some  remedy  not  known  to 
contain  it,  or  it  may  be  taken  up  as  a  pure  dissipation, 
but,  no  matter  how  its  use  is  begun,  when  the  addiction 
is  fully  established,  it  is  a  disease  and  the  victim  is  help- 
less and  cannot  abandon  the  use  of  the  drug  or  cure  the 
disease  by  merely  exercising  his  own  volition.  He  is  in 
the  toils  of  a  monster  with  whom  he  is  unable  to  cope, 
but  this  is  not  true  of  the  cocaine  habit. 

The  use  of  cocaine  is  usually  taken  up  by  those 
already  addicted  to  morphine.  In  the  course  of  two  or 
three  years  from  the  beginning  of  the  use  of  morphine 
it  ceases  to  exert  a  distinctly  stimulating  effect  on  the 
user.  There  is  little,  if  any,  pleasurable  sensation  from 
its  use.  It  is  continued  because  its  disuse  entails  suffer- 
ing which  the  victim  is  unable  to  bear. 

Morphine  users  who  are  inclined  to  dissipate,  after 
reaching  this  stage,  frequently  add  cocaine  for  the  stimu- 
lating and  pleasurable  sensations  produced  by  it,  they 

(425) 


426  Narcotic  Drug  Diseases  and  Allied  Ailments. 

not  being  satisfied  with  the  effects  of  the  morphine  alone. 
This  is  begun  and  continued  as  a  pure  dissipation.  It 
could  be  abandoned  any  day  without  material  suffering 
by  merely  dropping  the  cocaine  and  continuing  the 
morphine. 

There  is  no  more  difficulty  in  sobering  a  man  up  from 
a  cocaine  spree,  or  from  the  habitual  use  of  it,  than  in 
sobering  him  up  after  a  temporary  alcoholic  indulgence ; 
neither  is  there  greater  suffering  incident  to  it.  The 
habitual  use  of  cocaine  does  not  bring  on  a  disease  in 
any  way  comparable  to  that  of  morphine.  One  is  taken 
up  and  continued  purely  as  a  dissipation ;  the  other  is  a 
calamity,  and  so  enslaves  the  user  that  he  cannot 
abandon  it  of  his  own  volition. 

Cocaine  is  seldom  used  alone  habitually.  Its  use  in 
the  Southern  sections  of  the  United  States  is  confined 
almost  entirely  to  the  negro  race,  and  the  negroes  use 
it  intermittently.  The  power  of  cocaine  to  sustain  one 
under  a  prolonged  strain  is  well  understood  by  the  labor- 
ing class  of  negroes.  Frequently  those  engaged  in 
unloading  and  loading  steamers  will  work  forty-eight  to 
sixty  hours,  continuously,  by  supporting  themselves  with 
cocaine.  When  the  ship  is  loaded,  then  they  go  to  their 
quarters  and  sleep  two  or  three  days  before  even  rising 
to  take  food.  In  this  time  they  have  slept  off  the  effects 
of  the  cocaine  and  are  comparatively  normal.  Then  no 
more  is  taken  until  another  strain  comes  upon  them  and 
in  this  they  again  sustain  themselves  with  the  drug. 

Others  who  take  cocaine  as  a  dissipation  use  it 
through  the  night,  or  probably  through  a  day  and  night, 
and  then  abandon  it  for  a  time  and  later  go  on  another 
spree.  This  is  cheaper  to  them  than  alcoholic  intoxi- 
cation and  is  said  to  be  much  more  delightful. 

Persons  who  take  cocaine  alone  are  dangerous,  both 
to  themselves  and  others.  Cocaine  produces  delusions  of 


The  Immediate  Withdrawal  of  Cocaine.  427 

persecutions,  and,  acting  under  one  of  these  delusions, 
one  under  the  influence  of  cocaine  is  liable  at  any  time  to 
do  violence  to  anyone  near  him,  not  that  he  would  have 
any  ill  will  toward  the  particular  person;  but  believing 
that  he  is  being  pursued  by  some  enemy,  which  is  merely 
a  phantom,  he  is  liable  at  any  time  to  turn  and  use  a 
pistol  or  other  weapon  on  such  imaginary  enemy,  and  an 
innocent  party  be  maimed  or  killed.  It  is  never  safe  to 
allow  such  a  person  to  remain  at  liberty. 

The  most  insidious  and  damaging  manner  in  which 
cocaine  is  reaching  our  people,  that  is,  the  white  people 
of  this  country,  is  through  the  carbonated  drinks  for 
which  many  have  such  a  passion.  It  is  in  the  manu- 
facture of  such  drinks  that  the  bulk  of  cocaine  is  used. 
The  great  increase  in  the  importation  of  cocaine  leaves 
is  not  due  to  the  demand  for  cocaine  as  a  medicine,  or 
from  its  personal  use  by  drug  habitues,  but  it  is  because 
of  the  demand  for  the  leaves  as  the  one  essential  ingre- 
dient in  establishing  and  perpetuating  the  use  of  these 
carbonated  drinks. 

Many  of  these  drinks,  some  having  a  name  very  sug- 
gestive of  this  damaging,  yet  fascinating  drug,  have  been 
skillfully  and  persistently  advertised ;  but  their  use  and 
the  hold  they  have  upon  the  public  do  not  depend  upon 
this  skillful  use  of  printers'  ink,  but  upon  the  fact  that 
the  effect  of  one  drink  creates  a  demand  for  another. 

These  drinks  are  advertised  to  relieve  headache, 
overcome  fatigue,  and  impart  in  its  stead  a  sense  of 
exhilaration  and  well-being,  and  they  do  this,  but  not  by 
removing  the  cause  of  such  conditions,  nor  by  supplying 
the  system  with  the  physiological  activity  and  the  energy 
which  are  the  counterpart  of  these  unwelcome  condi- 
tions ;  they  do  it  by  blunting  the  sensibilities,  for  a  time, 
to  their  existence. 


428  Narcotic  Drug  Diseases  and  Allied  Ailments. 

As  the  effects  of  the  stimulant  in  the  drink  dies  out 
the  demand  for  another  drink  is  strongly  felt,  and  then 
a  second  drink  is  taken,  and  this  is  repeated  several  times 
a  day.  We  have,  as  a  result,  thousands  of  young  men 
and  women  depending  upon  the  energy  derived  from 
these  drinks  to  enable  them  to  carry  on  their  work. 
Many  of  them  taking  from  three  to  a  dozen  or  more  of 
these  medicated  soda-fountain  drinks  each  day.  They 
will  tell  you  that  they  feel  totally  unable  to  undertake 
their  day's  work  without  their  "coke." 

They  are,  in  fact,  as  really  enslaved  by  the  drugs 
these  drinks  contain  as  they  would  be  were  they  using 
them  in  other  form.  It  is  to  their  enslaving  properties 
that  these  drinks  owe  much  of  their  enormous  and  con- 
tinuous sale.  Doubtless,  when  the  facts  are  ascertained 
as  to  the  use  of  cocaine  by  the  school  children  of  Phila- 
delphia, which  has  recently  created  such  an  uproar,  it 
will  be  found  to  have  had  its  origin  in  the  medicated 
soda-fountain  drinks  rather  than  from  the  seductive 
influence  of  older  persons  used  in  a  more  direct  manner. 

Children  who  are  allowed  to  become  soda-fountain 
fiends  acquire  a  taint  that,  when  opportunity  presents, 
leads  them  to  take  to  cocaine  or  other  stimulants  like  a 
duck  to  water. 

TREATMENT. 

Much  misconception  exists  as  to  the  nature  and 
treatment  of  the  cocaine  habit.  When  cocaine  is  taken 
alone  the  treatment  consists  simply  in  cleaning  out  the 
system  by  an  active  cathartic,  shutting  off  the  cocaine, 
and  allowing  the  patient  to  go  to  sleep.  If  the  patient 
has  been  taking  a  considerable  quantity  of  cocaine  this 
sleep  will  continue  for  some  eighteen  to  thirty-six  hours, 
but  it  should  not  be  interrupted. 


Prolonged  Sleep  Following  Withdrawal.  429 

When  anyone  is  taking  cocaine  the  system  is  kept 
constantly  saturated  with  it  by  repeated  doses.  The 
effect  of  this  drug  is  to  keep  the  patient  excited,  in  a 
wakeful  state,  and  this  will  continue  as  long  as  the  doses 
are  regularly  repeated,  even  if  that  be  for  forty-eight 
hours  continuously  without  sleep.  Most  cocaine  users 
sleep  very  late  of  mornings,  but  before  they  are  able  to 
rise  from  bed  and  dress  themselves  they  must  have  one 
or  more  injections  of  their  drug.  This  puts  them  on 
their  feet  and  then  they  continue  to  take  their  doses  at 
short  intervals  from  that  time  until  late  the  next  night, 
or  they  may  run  even  a  day  and  night  in  succession 
before  they  stop  their  dosing  again  to  such  a  degree  as 
to  give  themselves  a  chance  to  sleep. 

But  usually  they  will  begin  their  day's  dosing  about 
10  to  12  o'clock  and  run  until  2  or  3  the  next  morning, 
and  then  leave  off  their  doses;  then  they  soon  become 
drowsy  and  go  to  sleep.  When  once  asleep  they  will 
sleep  so  heavily  that  the  sleep  will  be  continued  until 
nature  has  sufficiently  restored  the  system  to  enable  them 
to  arise  again.  As  soon  as  they  awake,  their  day's  work, 
which  consists  in  repeatedly  dosing  themselves  or  in- 
jecting cocaine,  again  begins  and  nothing  else  is  done. 
In  fact,  they  are  totally  unfit  for  application  to  business 
of  any  kind. 

If  cocaine  is  taken  in  connection  with  morphine  the 
condition  is  not  quite  so  bad,  but  few  people  who  take 
cocaine  will  do  anything  at  all  in  the  way  of  attention  to 
business.  After  they  get  to  taking  cocaine  in  consider- 
able quantities  it  requires  all  their  time  to  keep  the 
effects  of  that  drug  balanced  with  the  morphine  they 
are  taking. 

In  treating  such  a  case  a  thorough  course  of  elimina- 
tion should  be  given  so  that  the  medicine  will  act  early 


430  Narcotic  Drug  Diseases  and  'Allied  Ailments. 

in  the  morning.  Their  cocaine  should  be  given  to  them 
up  to  10  or  12  o'clock  at  night  and  then  taken  away. 
Within  two  or  three  hours  after  the  last  dose  of  cocaine 
the  patient  will  go  to  sleep  and  sleep  heavily  until  he  is 
aroused,  or  until  the  cocaine  effect  has  entirely  worn 
away. 

By  having  the  purgative  ready  to  act,  that  is,  by 
giving  the  purgative  so  it  will  be  ready  to  act  as  soon  as 
the  patient  awakens,  the  evacuation  of  this  toxic  matter 
relieves  the  nervous  system  to  a  considerable  extent,  and 
this  usually  quiets  the  patient  so  that  he  can  tolerate  his 
existence  without  the  cocaine. 

A  few  free  evacuations  of  the  bowels  give  sufficient 
relief  to  enable  him  to  go  back  to  sleep  and  then  twelve 
or  eighteen  hours  more  of  sleep  brings  him  to  a  condition 
of  comparative  quietude,  in  which  no  further  real 
demand  for  the  effects  of  cocaine  exists. 

Cocaine  should  be  discontinued  at  bedtime  on  the  first 
day  of  treatment  and  none  of  it  given  thereafter.  It  is 
true  the  patient  will  be  nervous  for  a  few  hours,  even 
after  his  prolonged  sleep  has  passed,  but  any  simple 
sedative  will  overcome  this  to  such  a  degree  as  to  enable 
him  to  bear  it  and  within  a  day  or  two  the  nervousness 
disappears  to  such  a  degree  that  further  medication  is 
not  necessary. 

There  is  no  severe  suffering ;  neither  is  there  danger 
in  withdrawing  cocaine  abruptly  from  the  patient  after 
the  portal  system  has  been  disengorged  and  the  bowel 
emptied.  There  is  no  reason  whatever  for  a  partial 
cutting  off  of  the  drug  or  for  the  reduction  of  the  dose 
before  it  is  abruptly  stopped. 

This  immediate  withdrawal  is  not  followed  by  a  col- 
lapse or  any  other  of  the  dangerous  complications  inci- 
dent to  the  withdrawal  of  opiates,  but  it  should  not  be 


Prognosis  Not  Favorable.  431 

practised  until  the  portal  system  is  disengorged,  the 
bowel  thoroughly  cleared,  and  the  heart  relieved  of  the 
burden  against  which  it  would  be  called  upon  to  work 
were  these  organs  left  in  the  contaminated,  engorged 
state. 

If  the  patient  is  taking  cocaine  and  morphine 
together,  then  the  treatment  for  the  morphine  disease 
may  go  hand  in  hand  with  the  treatment  for  the  cocaine 
habit.  The  author  finds  it  much  better  to  withdraw  both 
drugs  at  once,  so  far  as  the  physical  condition  of  the 
patient  is  concerned,  than  otherwise,  but  that  does  not 
hold  good  when  the  prognosis  is  considered.  Patients 
after  they  are  taken  off  of  cocaine  usually  sleep  even 
more  than  a  normal  person,  and  this,  to  a  large  extent, 
compensates  for  the  absence  of  sleep  due  to  the  with- 
drawal of  morphine.  In  many  cases  in  which  the  author 
has  withdrawn  morphine  and  cocaine  at  the  same  time, 
the  patient  has  slept  more  than  a  normal  person  would 
have  slept  during  the  first  two  or  three  weeks  after  such 
withdrawal.  This  is  a  very  delightful  experience  to 

them. 

PROGNOSIS. 

The  prognosis  in  the  cocaine  habit  is  usually  unfavor- 
able. Very  few  indeed  of  those  who  have  formed  the 
cocaine  habit  will  give  it  up  and  remain  free  from  it. 
That  is,  very  few  of  them  will  remain  free  if  both  the 
morphine  and  cocaine  are  taken  away  at  once. 

The  author  for  a  number  of  years  has  pursued  a 
different  plan  and  one  which  is  giving  good  results.  So 
far  as  the  physical  condition  is  concerned,  there  is  no 
reason  why  the  cocaine  should  be  taken  away  before  the 
opiate,  but  when  the  prognosis  is  considered  there  is  a 
reason  why  the  cocaine  should  be  first  discontinued. 

The  use  of  cocaine  is  usually  begun  as  a  dissipation. 
The  effect  of  the  cocaine  has  most  likely  increased  the 


432  Narcotic  Drug  Diseases  and  Allied  Ailments. 

tendency  to  dissipate  rather  than  otherwise,  but  in  some 
cases,  in  fact  in  many  cases,  the  individual  still  retains 
sufficient  reason  to  realize  the  damaging  effects  of  the 
use  of  these  drugs  combined.  When  that  is  true  and 
the  patient  can  be  led  to  abandon  the  cocaine  and  live  as 
much  as  twelve  months,  taking  morphine  alone,  the 
probability  of  his  remaining  free  from  both  drugs  is  very 
much  better  than  if  both  drugs  are  withdrawn  at  once. 

The  author  now  insists  that  a  man  who  is  using  co- 
caine and  morphine  is  not  in  condition  for  treatment  with 
the  expectation  of  his  cure  being  at  all  permanent,  unless 
he  is  taken  off  of  cocaine  and  then  required  to  continue 
the  use  of  morphine,  under  the  observation  of  some  com- 
petent medical  man,  for  a  period  of  twelve  months.  If 
the  individual  has  enough  self-control  left,  and  has 
determination  sufficient  to  discipline  himself  into  doing 
without  the  cocaine,  this  will  fit  him  for  treatment. 

After  a  year  of  this  kind  of  drilling  and  probation, 
he  can  be  taken  off  the  morphine  and  the  results  will 
almost  certainly  be  a  permanent  cure ;  but  if  he  be  taken 
off  the  cocaine  and  morphine  at  once,  the  mental  im- 
pressions left  by  the  cocaine  will  so  haunt  him  that 
the  chances  are  very  much  in  favor  of  his  returning  to 
either  or  both  of  the  drugs  in  a  very  short  time.  The 
author  prefers  not  to  take  cases  of  cocaine  habit,  unless 
they  place  themselves  under  his  care  for  a  period  of 
twelve  months  and  are  willing  to  pursue  the  course  above 
outlined. 

Cocaine  has  an  intensely  fascinating  effect,  one  that 
is  extremely  seductive  to  those  who  have  been  habituated 
to  its  use.  It  overcomes  all  sense  of  discomfort,  of  un- 
happiness,  and  brings  about  a  state  of  satisfaction  with 
the  conditions  that  exist  that  is  most  delightful  to  many 
persons.  When  a  person  has  been  addicted  to  morphine 
or  other  narcotic  drug  and  has  gotten  to  the  "down 


Cocaine  Not  Substitute  for  Morphine.  433 

and  out"  stage,  the  effects  of  cocaine  appeal  to  him  very 
strongly.  It  brings  him  surcease  from  all  of  his 
sorrows,  and  the  fascination  created  on  his  mind  is  such 
as  to  dominate  him,  and  it  is  a  rare  thing  that  he  can  be 
led  to  give  it  up. 

But  if  he  still  retains  that  degree  of  self-control  that 
will  enable  him  to  give  up  the  cocaine  and  continue  the 
use  of  morphine  in  uniform  and  moderate  quantities  for 
as  much  as  twelve  months,  he  still  retains  sufficient  self- 
control  and  moral  purpose  to  make  a  good  and  successful 
fight  against  the  morphine  disease.  Persons  who  will 
faithfully  carry  out  this  disciplinary  course  are  developed 
into  a  condition  favorable  for  treatment. 

Cocaine  was  once  lauded  as  a  cure  for  the  "mor- 
phine habit"  and  many  began  its  use  with  this  idea,  only 
to  find  themselves  enslaved  by  two  drugs.  The  use  of 
cocaine  as  a  nasal  spray  is  another  source  from  which 
its  abuse  has  sprung  in  a  few  cases.  The  author  has  had 
several  cases  of  this  type  who  use  the  drug  in  no  other 
way,  but  were  continually  spraying  their  nose  and 
mucous  surfaces  with  cocaine.  These,  evidently,  ob- 
tained but  little  systemic  effect  from  the  cocaine,  but  if 
the  author's  information  is  correct  all  but  one  of  them 
resumed  the  use  of  the  spray  after  treatment. 

Keibler,  in  the  U.  S.  Dept.  of  Agriculture,  is  quoted 
as  saying:  "Cocaine  is  fast  taking  the  place  of  mor- 
phine." The  author  cannot  understand  such  a  statement 
coming  from  one  having  knowledge  of  the  effects  of  the 
two  drugs.  These  effects  are  not  at  all  similar  and 
cannot  be  made  to  take  the  place  one  of  the  other;  in 
fact,  their  effects  are  so  different  that  cocaine  is  rec- 
ognized as  one  of  the  antidotes  in  morphine  poison. 
About  10  per  cent,  of  morphinists  use  cocaine  with  their 
morphine. 


28 


CHAPTER  XXIII. 

CHRONIC  ALCOHOLISM 

UNTIL  the  last  quarter  of  a  century,  alcoholism  was 
almost  universally  regarded  as  a  mere  moral  perversion, 
a  bad  habit  entered  into  and  continued  because  of  moral 
degeneracy.  Numerous  efforts  were  made  to  reclaim 
and  reform  the  drunkard.  Almost  all  of  these  consisted 
in  an  appeal  to  the  moral  and  emotional  nature  of  drink- 
ing men  and  many  were  thus  influenced  to  abandon  the 
use  of  alcohol,  but  a  large  majority  were  unr cached  by 
these  efforts. 

In  more  recent  years  the  wretched  condition  of  these 
men  has  appealed  strongly  to  scientific  men  who  were 
students  of  human  nature  as  well  as  of  abstract  science, 
and  the  causes  or  influences  which  led  such  men  to 
enter  upon  and  continue  the  use  of  alcoholic  beverages 
have  been  studied  from  every  viewpoint.  These  studies 
have  fully  established  the  fact  that  only  in  a  very  small 
percentage  of  cases  is  alcoholism  a  mere  moral  perver- 
sion, but  that  it  is  in  the  truest  sense  a  disease,  a  disease 
having  a  well-defined  and  demonstrable  pathology. 

Since  the  disease  theory  of  chronic  alcoholism  has 
been  accepted,  the  question  has  naturally  arisen :  What 
can  be  done  by  treatment  for  this  disease  ?  Is  it  curable  ? 
To  this  last  question  both  an  affirmative  and  a  negative 
answer  can  be  made  and  each  will  be  correct  when  ap- 
plied to  a  certain  class  of  cases. 

Chronic  alcoholism  is  not  only  a  disease  itself,  but  in 
many  instances  it  springs  from  other  diseases  and  it  is 
certain  that  other  diseases  grow  out  of  it.  These  dis- 
eases may  be  either  physical,  mental,  or  moral.  To  cure 
(434) 


Alcoholic  Subjects  Classified.  435 

any  disease  the  cause  must  be  removed.  In  some  cases 
of  alcoholism  this  can  be  done  by  treatment;  in  others, 
it  cannot;  hence  the  question  naturally  arises:  What 
class  of  cases  is  curable  and  what  is  not? 

In  endeavoring  to  answer  this  question,  it  is  neces- 
sary to  consider  the  type  of  the  addiction  as  well  as  the 
influences  which  led  to  its  formation.  For  the  purpose 
of  study,  as  well  as  for  treatment,  it  is  best  to  divide 
alcoholic  subjects  into  two  general  classes,  regular 
drinkers  and  periodic  drinkers. 

There  is  wide  difference  between  the  influences  which 
lead  the  periodic  alcoholic  to  go  on  a  spree  and  those 
which  prompt  the  regular  drinker  to  continue  the  use  of 
his  beverage. 

REGULAR   DRINKERS. 

Probably  80  per  cent,  of  all  persons  who  habitually 
drink  alcoholic  beverages  form  the  habit  inadvertently, 
unintentionally,  and  without  any  definite  purpose  in 
view.  Among  them  may  be  found  persons  of  the  highest 
aims  who,  primarily,  had  sound  bodies  and  minds  and 
good  habits,  but  who  began  the  use  of  alcoholic  bever- 
ages in  a  social  way  or  with  the  erroneous  idea  that  the 
effects  of  the  alcohol  would  protect  them  from  some 
prevalent  disease,  such  as  malaria,  etc. 

Such  persons  continue  the  use  of  alcoholic  drinks 
without  mature  thought  as  to  their  effects  on  them  and 
certainly  without  any  purpose  to  go  to  excess  or  to  dis- 
sipate in  any  way;  but  no  matter  how  begun,  the  fre- 
quent use  of  even  a  small  quantity  of  alcohol  creates  a 
demand  for  increasing  quantities,  and  this  grows  by 
almost  imperceptible  degrees  until  there  is  a  daily  con- 
sumption of  considerable  quantities  of  some  alcoholic 
drink. 


436  Narcotic  Drug  Diseases  and  Allied  Ailments. 

-*  For  a  time  the  effects  of  this  beverage  seem  to 
improve  the  health,  to  impart  greater  mental  and  physi- 
cal vigor  and  generally  to  promote  the  well-being  of  the 
subject,  but  these  benefits  are  more  apparent  than  real. 
In  fact,  they  are  not  real  at  all,  the  effects  of  this  agent 
having  merely  built  up  a  state  of  apparent  hypernutrition 
by  increasing  fatty  metabolism  and  decreasing  waste. 

In  this  manner  an  unwholesome  bodily  state  is 
brought  about  in  which  the  demand  for  the  effects  of 
alcohol  is  increasingly  felt,  and  because  of  which  the 
victim  is  only  comfortable  when  under  the  influence  of 
alcohol.  Almost  imperceptibly  the  demand  for  stimu- 
lants grows,  the  victim  becomes  more  and  more  de- 
pendent on  them,  and  larger  and  larger  quantities  are 
required  to  meet  the  demand. 

The  daily  consumption  of  these  considerable  quanti- 
ties of  alcohol  necessarily  brings  about  such  changes  in 
the  system  as  to  create  an  imperative  demand  for  their 
continuation. 

After  reaching  this  stage,  the  victim  feels  that  he 
cannot  begin  his  day's  work  without  his  morning  drink; 
there  is  a  degree  of  lassitude,  a  lack  of  vigor  which  he 
seems  totally  unable  to  throw  off  without  the  aid  of  his 
stimulant.  As  the  disorders  growing  out  of  the  use  of 
alcohol  progress,  one  drink  is  not  sufficient  to  give  the 
desired  support;  then  two,  three,  or  more  are  taken  in 
close  succession,  and  this  bracing  process  is  continued 
throughout  the  day,  from  day  to  day,  and  from  week  to 
week. 

The  effects  of  this  prolonged  and  free  use  of  alcohol 
bring  serious  impairment  of  the  digestive  organs,  the 
appetite  is  variable  or  absent  altogether  unless  freshly 
stimulated  by  an  extra  drink,  and  if,  at  this  or  any  sub- 
sequent stage,  the  victim  makes  an  effort  to  discontinue 


Disorders  from  Alcoholism.  437 

drinking  such  a  state  of  nervousness  arises  as  to  drive 
him  to  resume  the  stimulant. 

The  entire  system  has  by  this  time  become  so  satu- 
rated with  toxic  matter  that  a  condition  of  intolerable 
nervousness  arises  whenever  the  system  is  allowed  to  get 
from  under  the  now-sedative  effects  of  alcohol,  and,  no 
matter  how  acutely  conscious  of  his  slavery  the  victim 
may  have  become  or  how  heroically  he  may  struggle  to 
throw  off  the  yoke,  he  finds  himself  unable  to  do  so  by 
his  own  efforts. 

The  prolonged  free  use  of  alcohol  brings  on  such 
disorders  of  the  system  as  to  lead  the  best  of  men,  when 
in  its  grasp,  to  continue  to  seek  relief  from  these  dis- 
orders by  increasing  the  quantity  of  alcohol  consumed. 
Whether  that  course  is  imperatively  necessary  or  not,  it 
appeals  to  them  as  being  the  one  readily  available  remedy, 
the  panacea  for  every  ill,  and  it  is  so  used. 

A  majority  of  habitual  users  of  alcohol  in  this  coun- 
try belong  to  this  class,  and  many  of  them  would  gladly 
quit  drinking  if  they  could  ever  get  the  poison  out  of 
their  systems  and  reach  a  state  in  which  they  could  live 
in  comfort  without  it,  but  they  seem  never  to  be  able  to 
do  so.  They  never  become  entirely  sober  and  their 
systems  are  never  normally  free  from  the  products  of 
tissue  waste ;  on  the  contrary,  they  are  habitually  in  an 
extremely  toxic  condition  and  are  comfortable  only  when 
the  paralyzing  effects  of  alcohol  blunts  their  sensibilities 
to  the  irritating  effects  of  this  poison. 

In  habitues  of  this  class,  the  addiction  has  a  purely 
physical  basis  which  is  the  product  of  alcohol  alone. 
This  consists  of  both  structural  lesions  and  functional 
derangements,  but  the  structural  lesions  have  little  in- 
fluence toward  impelling  the  victim  to  continue  the  use 
of  alcoholic  drinks. 


438  Narcotic  Drug  Diseases  and  Allied  Ailments. 

The  functional  derangements  are  usually  the  only 
disorders  growing  out  of  the  use  of  alcohol  of  which 
he  is  conscious,  but  these  throw  him  into  extreme  dis- 
tress when  he  attempts  to  go  without  the  aid  alcohol 
gives  him.  These  functional  derangements  consist 
mainly  of  a  chronic  catarrh  of  the  stomach,  accompanied 
by  an  intensely  toxic  condition  of  the  system,  but,  as 
these  yield  readily  to  proper  treatment,  alcoholic  patients 
of  this  class  are  curable. 

It  is  folly  to  talk  to  a  man  in  such  condition  as  this 
about  reforming  his  life  and  stopping  the  use  of  stimu- 
lants by  his  own  efforts.  The  forces  which  impel  him  to 
continue  the  use  of  alcohol  are  stronger  than  any  will- 
power he  is  able  to  exert.  In  order  to  put  him  in 
condition  so  that  his  own  will,  his  normal  impulses,  may 
control  him,  his  system  must  be  thoroughly  renovated 
and  the  physical  demand  for  the  effects  of  alcohol  re- 
moved ;  then  his  moral  nature  can  assert  itself,  and  then, 
and  then  only,  can  he  control  himself  by  the  exercise  of 
his  will  power. 

In  the  second  class  of  regular  drinkers  the  author 
would  place  a  small  percentage  of  persons  who  were  born 
with,  or  who  from  disease  in  early  life  acquired,  a  defect- 
ive physique  and  an  unbalanced  nervous  system,  persons 
who  because  of  such  defects  have  never  been  normal 
either  in  nervous  system  or  physical  organization. 
When  such  persons,  in  seeking  something  to  overcome 
their  habitual  discomfort,  experience  the  effects  of  alco- 
hol they  readily  fall  victims  to  its  seductive  influences. 
For  a  time  it  seems  to  fill  the  vacant  place  and  to  be  the 
one  thing  lacking  in  their  lives;  it  overcomes  that  dis- 
cordant nervous  condition  which  they  so  much  dread, 
and  they  feel  that  they  have  found  a  panacea  for  all  their 
ills,  but  this  relief  is  of  short  duration. 


Types  of  Regular  Drinkers.  439 

The  demand  for  the  effects  of  alcohol  grows  very 
rapidly  in  such  persons,  and  its  continued  use  brings  on 
the  same  pathological  changes  that  it  does  in  others.  The 
system  soon  becomes  extremely  toxic.  This  irritating 
matter  greatly  aggravates  their  former  nervousness,  so 
that  the  two  conditions  together  now  make  such  an 
imperative  demand  for  the  effects  of  alcohol  that  the 
victim  cannot  resist  it  and  he  keeps  himself  constantly 
saturated  with  alcohol ;  in  fact,  after  reaching  this  stage, 
he  must  do  so  to  enjoy  the  least  degree  of  comfort. 

But  little  can  be  expected  from  treatment  in  this  class 
of  cases  unless  it  is  found  that  the  original  discordant 
nervous  element  can  also  be  removed  by  treatment. 
When  it  is  found  that  these  causative  conditions  are  such 
as  to  be  amenable  to  treatment,  and  the  treatment  for 
the  addiction  embraces  not  only  such  treatment  as  would 
be  necessary  to  give  relief  in  an  ordinary  case,  but  also 
such  other  measures  as  may  be  required  to  restore  the 
primarily  unbalanced  nervous  system  to  a  normal  condi- 
tion, much  benefit  may  be  derived  from  treatment  even 
in  these  unpromising  cases,  provided  a  reasonable  degree 
of  moral  fiber  was  originally  present. 

In  a  third  class  the  author  would  place  another, 
relatively  small  proportion  of  regular  drinkers.  To  this 
class  belong  those  who  drink  as  a  pure  dissipation, 
persons  who  are  deficient  in  moral  fiber,  lacking  in  pur- 
pose, supremely  selfish,  willing  to  gratify  the  desires  of 
the  present  moment  at  any  cost  to  themselves  or  others ; 
those  who  are  simply  drifting  through  the  world  without 
a  rudder,  compass,  or  objective  port. 

These  defective  traits  of  character  may  be  due  either 
to  inherited  tendencies  or  to  early  environment.  Persons 
of  this  class  drink  because  they  prefer  to  do  so,  and  they 
would  return  to  the  use  of  alcoholic  drinks  even  if  some- 


440  Narcotic  Drug  Diseases  and  Allied  Ailments. 

one  took  them  up  and  gave  their  system  a  thorough 
renovating  and  removed  all  physical  necessity  for  the 
effects  of  such  drinks. 

In  cases  of  this  class  more  than  human  agency  would 
be  necessary  to  effect  a  cure.  Not  only  would  it  be  neces- 
sary to  renovate  their  bodies  and  put  them  in  normal 
physical  condition,  but  it  would  be  necessary  to  effect 
a  most  radical  change  in  their  moral  nature,  a  complete 
transformation  of  their  purposes  in  life,  and  nothing 
short  of  the  grace  of  God  is  sufficient  for  such  a  work. 
Human  agency  will  not  avail. 

Fortunately,  only  a  small  proportion  of  the  regular 
drinkers  belong  to  either  of  the  two  classes  last  men- 
tioned; the  great  majority  are  of  the  class  first  described 
in  this  chapter.  They  are  men  of  good  families,  of  excel- 
lent traits  of  character,  of  high  aims,  chivalrous, 
generous  to  a  fault,  truthful,  and  honest;  in  fact,  most 
of  them  are  men  with  whom  no  fault  can  be  found,  except 
this  one  weakness,  and  that  due  to  the  fact  that  they 
have  fallen  into  the  clutches  of  this  monster. 

Victims  of  this  class  continue  to  drink  only  because 
their  will-power  and  self-control  and  their  ability  to 
estimate  correctly  their  own  condition  have  been  so 
undermined  by  the  effects  of  alcohol  that  they  cannot 
extricate  themselves  from  its  clutches,  they  cannot  of 
themselves  retrace  their  steps.  On  arising  in  the  morn- 
ing, they  find  themselves  totally  unable  to  begin  their 
day's  work  without  the  bracing  effects  of  alcohol,  and 
because  of  the  urgency  of  this  physical  demand  they 
continue  to  seek  what  relief  they  can  get  from  it  from 
day  to  day. 

When  such  men  as  these  are  freed  from  the  domina- 
tion of  alcohol ;  when  the  physical  demand  for  it  is  over- 
come and  they  are  put  in  a  normal  condition,  they  almost 


Types  of  Periodic  Drinkers.  441 

invariably  remain  permanently  free  from  it.  Failure  to 
benefit  permanently  such  men  as  are  described  in  the 
second  and  third  divisions  above  mentioned  should  not 
be  allowed  to  discourage  us  or  to  render  us  less  enthu- 
siastic in  our  efforts  to  rescue  the  more  numerous  and 
really  noble  army  of  enslaved  ones. 

PERIODIC  ALCOHOLISM. 

There  is  a  wide  difference  between  the  influences 
which  lead  to  periodic  alcoholic  sprees  and  those  which 
lead  the  regular  drinker  to  continue  the  use  of  his  bever- 
age. Periodic  alcoholism  may  spring  from  a  variety  of 
causes,  but  these  may  be  studied  to  advantage  under  four 
types,  which  may  be  enumerated  as  follows :  ( I )  dipso- 
mania, real  or  symptomatic;  (2)  moral  cowardice;  (3) 
bad  environment,  with  lack  of  stability  of  character,  and 
(4)  bad  environment,  with  an  ever-present,  but  usually 
successfully  resisted,  appetite  for  liquors. 

DIPSOMANIA. 

Dipsomania  is  denned  to  be  "an  uncontrollable  desire 
for  strong  drink,"  but  this  term  should  be  restricted  to 
those  cases  in  which  this  desire  or  impulse  springs  from 
a  real  mental  disorder,  a  true  mania.  It  should  not  be 
applied  to  cases  in  which  the  desire  for  drink  only  be- 
comes uncontrollable  when  it  is  excited  or  intensified 
by  some  general  physical  derangement,  or  to  cases  in 
which  the  desire  is  continuous.  A  better  definition  would 
be:  periodic  insanity  taking  the  form  of  an  uncon- 
trollable desire  for  strong  drink. 

Real  dipsomania  is  very  rare,  but  that  it  does  exist 
cannot  be  denied.  Most  writers  leave  the  impression 
that  such  attacks  are  due  entirely  to  some  obscure  struc- 
tural brain  lesion  or  inherited  mental  defect.  It  is 


442  Narcotic  Drug  Diseases  and  Allied  Ailments. 

doubtless  true  that  there  are  persons  in  whom  a  real 
mania  of  this  type  occurs  because  of  an  inherited  mental 
bias  or  perverted  nervous  organization,  independently  of 
the  general  physical  condition,  but,  in  the  author's  judg- 
ment, such  cases  are  extremely  rare. 

In  a  large  majority  of  cases  which  are  thus  classified, 
the  attack  occurs  only  when  excited  by  an  added  systemic 
derangement,  such  as  an  acute  intestinal  toxemia.  The 
irritating  effect  of  this  toxic  matter  serves  as  an  exciting 
cause  of  an  outbreak.  In  many  instances  these  attacks 
may  be  warded  off  or  prevented  altogether  by  keeping 
the  system  free  from  toxic  matter. 

Where  outbreaks  of  this  kind  occur  solely  as  the 
result  of  an  inherited  mental  defect,  treatment  cannot  be 
expected  to  be  of  material  benefit ;  but  in  cases  in  which 
such  attacks  occur  only  when  an  exciting  cause,  such  as 
an  acute  toxemia,  contributes  its  influence,  then  treat- 
ment can  be  a  material  benefit,  provided  it  embraces 
such  instructions  in  the  manner  of  living  as  to  enable  the 
victim  to  avoid  the  occurrence  of  these  toxic  states. 

MORAL  COWARDICE. 

Another  and  probably  the  most  hopeless  class  of 
periodic  drinkers  are  those  who  drink  as  an  expression 
of  moral  cowardice.  These  are  men  who  have  no  par- 
ticular craving  or  appetite  for  liquors,  who  will  say  at 
almost  any  time  that  they  do  not  care  for  the  taste  or 
primary  effects  of  alcoholic  drinks,  but  who  have  learned 
from  experience  that  alcohol  will  blunt  their  sensibilities 
and  bring  them  surcease  from  cares  and  worries  which 
they  have  not  the  manhood  and  moral  courage  to  take  up 
and  bear,  and  from  time  to  time  they  seek  forgetfulness 
in  the  effects  of  alcohol. 

A  man  of  this  class  will  quarrel  with  his  wife  or  a 
friend  and  go  off  and  get  drunk  for  spite,  or  he  may 


Causes  of  Alcoholism.  443 

have  some  adverse  business  experience  which  to  others 
would  be  trivial,  but  he,  not  having  the  moral  courage  to 
face  it,  runs  from  it  and  seeks  oblivion  in  the  effects  of 
alcohol. 

Little,  if  any,  good  can  come  from  treatment  in 
patients  of  this  class.  Therapeutic  measures  cannot  re- 
move from  their  lives  these  defective  traits  of  character 
or  impart  to  them  that  degree  of  moral  courage  which 
is  needed  to  fit  them  to  fight  the  battles  of  life  in  the  open 
and  resist  the  adverse  currents  which  drift  them  from  a 
safe  and  sober  mooring. 

INSTABILITY   OF  CHARACTER  WITH   BAD 
ENVIRONMENT. 

In  another  class  of  periodic  drinkers  the  sprees  are 
due  to  bad  environment  coupled  with  instability  of  char- 
acter. These  are  the  social  drinkers  who  lose  control  of 
themselves  as  soon  as  one  drink  is  taken.  Many  of  these 
are  men  of  estimable  qualities,  amiable,  chivalrous,  good- 
hearted,  kind,  and  in  every  way  lovable  men,  but  they 
are  deficient  in  self-control,  fixed  purposes,  and  positive 
traits  of  character. 

They  are  good-natured  fellows  who  drift  with  the 
current  and  allow  others  to  dictate  their  course.  These 
men,  when  away  from  their  drinking  associates  and  out 
of  temptation,  remain  entirely  sober  and  would  not  think 
of  going  alone  and  deliberately  beginning  to  drink ;  they 
have  no  craving  or  appetite  for  liquor  which  they  are  not 
fully  able  to  control,  but  they  are  negative  characters  and 
when  thrown  with  drinking  associates  they  do  as  others 
do.  They  are  of  the  type  of  social  drinkers  who  lose 
control  of  themselves  as  soon  as  they  are  slightly  under 
the  influence  pf  liquor.  When  once  started,  such  men 
continue  to  drink  until  someone  takes  control  of  them 


444  Narcotic  Drug  Diseases  and  Allied  Ailments. 

and  assists  them  to  get  out  of  the  adverse  currents. 
Then  a  period  of  entire  sobriety  follows,  only  to  end  in 
another  spree  when  they  again  come  under  these  un- 
wholesome influences. 

Treatment  in  such  cases  can  be  successful  only  when 
followed  by  an  entire  change  of  environment.  Not  only 
must  the  old  associates  be  given  up,  but  the  one  seeking 
to  reform  his  life  must  be  thrown  with  sober  and  moral 
people  whose  positive  influence  for  good  over  him  will 
be  sufficient  to  enable  him  to  stand  firmly  in  his 
new  position  notwithstanding  his  defective  traits  of 
character. 

BAD  ENVIRONMENT  WITH  AN  EVER-PRESENT, 
BUT  RESISTED  APPETITE. 

Another  type  of  periodic  drinkers  are  those  who  have 
an  inherited  or  acquired  thirst  or  craving  which  is  ever 
present  with  them,  but  who,  from  strong  convictions, 
contend  against  this  weakness  with  a  courage  that  in 
many  cases  is  really  heroic,  and  under  favorable  circum- 
stances they  succeed  in  controlling  themselves,  but  when 
thrown  with  drinking  associates,  or  when  brought  under 
other  strong  temptation,  they  find  themselves  unable  to 
resist  both  the  ever-present  thirst  and  the  temptation. 

Under  these  circumstances  they  begin  to  drink,  and 
as  soon  as  one  drink  is  taken  their  resisting  power  is 
gone,  and  they  throw  themselves  into  the  spree  with  a 
vigor  and  abandon  which  is  not  known  to  the  more  timid 
or  less  resolute.  They  continue  to  drink  until  the  stom- 
ach rebels  and  will  no  longer  retain  the  liquor ;  then  they 
go  through  a  period  of  extreme  distress  and  remorse, 
and  finally  get  back  on  their  feet. 

Periodic  drinkers  of  this  type  are  more  amenable 
to  treatment  than  any  other  form  of  periodic  drinkers, 


Principles  of  Treatment.  445 

because  the  craving,  the  thirst  against  which  they  con- 
tend, can  be  overcome;  in  fact,  entirely  destroyed.  In 
addition  to  this,  their  attitude  toward  liquor  can  be  so 
changed  as  to  render  its  taste,  smell,  and  effects  repulsive 
to  them.  When  men  of  this  type  are  given  this  much 
aid,  they  find  themselves  quite  able  to  contend  success- 
fully against  the  influence  of  drinking  associates  and  to 
resist  other  currents  of  influence  which,  when  associated 
with  their  former  craving,  would  have  been  sufficient  to 
cause  them  to  fall. 

PRINCIPLES  OF  TREATMENT. 

Before  undertaking  to  treat  any  disease,  we  should 
endeavor  to  ascertain  the  nature  of  the  condition  to  be 
met;  whether  such  a  condition  has  a  real,  structural 
pathology  or  is  only  a  functional  derangement,  and 
whether  it  is  a  physical  or  a  mental  disorder.  That  the 
prolonged  use  of  alcoholic  drinks  does  cause  serious 
structural  lesions  of  the  brain,  liver,  stomach,  and  other 
organs  cannot  be  denied,  but  such  lesions  are  not  the 
only  or  even  the  principal  reason  for  the  continuation  of 
the  habit. 

In  some  cases,  as  we  have  seen  in  the  preceding,  the 
use  of  liquors  is  continued  from  preference,  or  because 
of  some  mental  or  moral  defect,  but  in  the  great  majority 
of  cases  alcoholic  drinks  are  continued  because  of  a 
strong  demand  in  the  system  for  their  effects. 

The  habit  has  a  real  physical  basis.  This  demand  for 
the  effects  of  alcohol  is  due  mainly  to  the  toxic  condition 
of  the  system.  Alcohol  blunts  the  sensibilities  of  the 
nervous  system  and  retards  the  excretion  of  the  prod- 
ucts of  waste.  The  life  of  the  human  organism  is  a  con- 
tinuous process  of  waste  and  repair. 

When  the  excretion  of  this  waste  is  retarded,  even 
to  a  slight  degree,  day  by  day,  the  system  finally  becomes 


446  Narcotic  Drug  Diseases  and  Allied  Ailments. 

so  saturated  with  poisonous  matter  as  to  cause  serious 
functional  derangement  of  every  organ  in  the  body. 

One  in  this  condition  finds  it  necessary  to  keep  the 
nervous  system  constantly  blunted  with  the  effects  of 
alcohol  or  other  narcotic  in  order  to  obtain  a  reasonable 
degree  of  comfort.  While  it  is  true  that  alcohol  has 
caused  these  disorders,  still  its  effects  relieve  the  acute 
distress  springing  from  them  more  promptly  and  in  a 
manner  more  acceptable  to  the  sufferer  than  anything 
else  with  which  he  is  familiar ;  therefore,  he  continues  to 
seek  what  comfort  he  can  get  by  taking  more  alcohol, 
and  thereby  burns  the  taper  at  both  ends. 

In  endeavoring  to  bring  about  such  a  change  in  this 
condition  as  to  render  the  further  use  of  alcohol  un- 
necessary, the  first  and  most  important  step  is  thoroughly 
to  cleanse  the  system  from  the  products  of  waste  which 
the  effects  of  alcohol  have  forced  it  to  retain.  In  doing 
this  the  bowels,  kidneys,  and  skin  should  all  be  made  to 
do  their  full  share;  in  fact,  for  a  time  these  should  be 
made  to  do  many  times  their  ordinary  duty. 

Just  in  proportion  as  the  excess  of  toxic  matter  is 
eliminated  will  the  nervous  system  become  quiet  and  the 
urgent  demand  for  the  effects  of  alcohol  disappear.  As 
a  rule,  in  the  course  of  three  or  four  days  the  system  can 
be  so  cleansed  of  toxic  matter  as  to  permit  the  with- 
drawal of  alcohol  without  risk  or  discomfort  to  the 
patient. 

The  author  does  not  consider  it  safe,  or  at  all  advis- 
able, to  withdraw  alcoholic  liquors  abruptly  from  one 
who  has  been  using  them  in  large  quantities  without  first 
preparing  the  system  for  such  withdrawal.  After  the 
system  is  properly  prepared  for  the  withdrawal,  it  can 
be  made  with  safety  and  without  discomfort,  but  we 
cannot  agree  with  the  arbitrary  rule  of  cutting  off  the 
alcohol  as  soon  as  the  patient  is  taken  in  hand. 


Alcoholism,  Principles  of  Treatment.  447 

Up  to  this  point,  the  treatment  in  the  several  classes 
of  alcoholic  cases  is  practically  the  same,  as  all  of  them 
require  elimination  of  the  toxic  matter  and  the  with- 
drawal of  alcohol,  but,  from  this  point  on,  the  several 
classes  will  require  radically  different  lines  of  treatment. 

The  particular  nature  of  the  treatment  required  to 
complete  the  cure  will  depend  on  the  cause,  or  set  of 
causes,  which  originally  led  to  the  formation  of  the 
habit,  as  well  as  those  which  have  had  an  influence  in  its 
continuation.  If  these  were  purely  mental,  then  treat- 
ment calculated  to  overcome  a  mental  disorder  should  be 
given ;  if  they  were  moral  or  social,  then  these  influences 
should  be  looked  into  and  every  effort  made  to  direct  the 
patient's  future  life  so  as  to  protect  him  from  these 
damaging  influences  and  prevent  a  return  to  his  old 
haunts  and  habits. 

If  the  patient  belongs  to  the  more  promising  class, 
the  regular  drinkers  in  whom  the  habit  was  continued 
because  of  the  usual  mental  bias  favorable  to  the  use  of 
alcohol,  and  because  of  the  deranged  physical  condition 
resulting  from  its  effects,  then  the  succeeding  steps  in  the 
treatment  should  be  to  neutralize  or  eliminate  the  rem- 
nant of  alcohol  remaining  in  the  blood,  to  overcome  any 
appetite  which  may  remain  for  it,  and  to  supplant  the 
mental  bias  favorable  to  alcohol  with  a  dislike  or  com- 
plete disgust  both  for  its  taste  and  effect. 

In  cleansing  the  system  from  toxic  matter  cathartics 
are,  of  course,  our  most  valuable  agents,  but  to  get  the 
best  results  from  cathartics  it  is  well  to  combine 
podophyllin  with  the  other  ingredients.  It  has  a  more 
prolonged  action  than  the  other  purgative  ingredients, 
and  alcoholic  patients  not  only  need  its  effect,  but  stand 
podophyllin  well.  The  following  formula  is  one  which 
the  author  has  used  to  good  advantage : — 


448  Narcotic  Drug  Diseases  and  Allied  Ailments. 

3^  Calomel, 

Powdered  extract  of  cascara aa  gr.  x. 

Podophyllin gr.  j. 

Strychnine  nitrate gr.  %o- 

Atropine  sulphate gr.  %0. 

Mix  and  make  4  capsules ;  write,  one  every  two  hours  on 
an  empty  stomach. 

In  this  formula  each  dose  contains  2^/2  grains  of 
calomel,  2l/2  grains  of  cascara,  %  grain  of  podophyllin, 
%o  grain  of  strychnine,  and  ^200  grain  of  atropine, 
differing  from  the  one  used  in  drug  patients  by  the 
addition  of  the  podophyllin,  which  remedy  drug  patients 
do  not  stand  well  and  by  the  reduction  of  the  strychnine 
from  l/2o  to  %o  grain  for  each  dose.  Alcoholics  do  not 
require  as  much  strychnine  to  stimulate  active  peristalsis 
as  do  drug  patients ;  neither  do  they  stand  strychnine  so 
well  as  drug  patients  do. 

One  course  of  purgative  medicine  will  do  much 
toward  cleansing  the  system  of  an  alcoholic  and  relieving 
the  urgent  demands  for  alcoholic  drinks,  but  it  does  not 
fully  accomplish  that  result.  It  is  best  to  follow  this 
course  with  salts  or  oil  in  ten  or  twelve  hours  after  the 
last  capsule  is  taken.  If  these  act  freely  it  is  then  best 
to  give  the  patient  nourishment  and  allow  a  full  day's 
rest  from  purgatives.  The  alcohol  should  be  reduced  in 
quantity,  but  not  withdrawn  altogether  -  until  further 
advance  is  made  in  the  treatment. 

Forty-eight  hours  from  the  time  of  giving  the  first 
purgative  course  another  of  the  same  character  should 
be  given  and  this  followed  by  oil  or  salts,  as  before. 
These  two  courses  will  usually  cleanse  the  system  to  such 
a  degree  as  to  permit  the  discontinuance  of  alcoholic 
drinks,  and  this  should  be  done  as  soon  after  the  second 


Alcoholism,  Details  of  Treatment.  449 

purgative  course  as  the  condition  of  the  patient  will 
allow,  but,  if  he  is  still  very  nervous  or  is  threatened 
with  delirium  tremens,  alcoholic  drinks  should  be  con- 
tinued in  reduced  quantities,  and  these  should  be  grad- 
ually reduced  until  discontinued. 

The  patient  should  be  urged  to  drink  as  much  water 
as  possible  and  a  vapor  bath  each  day  will  also  aid 
materially  in  cleansing  the  patient's  system  and  over- 
coming his  nervousness. 

The  author  does  not  think  electricity  in  any  form 
has  much,  if  any,  value  in  these  cases.  Hydrotherapeutic 
measures,  however,  are  of  the  greatest  value  and  should 
be  freely  and  persistently  used. 

For  the  relief  of  nervousness  and  insomnia,  which 
are  often  due  to  cerebral  hyperemia,  the  author  has 
found  gelsemium  a  remedy  of  the  greatest  value.  Three 
to  5  minims  of  the  specific  tincture  of  gelsemium  every 
two  to  four  hours  by  the  mouth,  or  l/2  5  grain  gelseminine 
hypodermically  at  the  same  intervals,  adds  greatly  to  the 
comfort  of  the  patient  and  diminishes  the  liability  to 
delirium  tremens. 

It  is  the  author's  rule  to  keep  the  patient  well  under 
the  influence  of  gelsemium  during  the  first  week  of  treat- 
ment. It  is  a  cerebral  sedative,  a  motor  depressant,  and 
overcomes  the  distressing  nervousness  of  the  patient  to 
such  a  degree  that  the  alcohol  may  be  withdrawn  more 
promptly  and  with  much  less  distress. 

After  the  patient's  system  has  been  cleansed  of  toxic 
matter,  alcohol  withdrawn,  and  all  danger  of  delirium 
tremens  has  passed,  then  strychnine  nitrate,  l/2o  grain 
from  three  to  five  times  per  day,  hypodermically,  will  do 
much  to  overcome  the  appetite  or  desire  for  alcoholic 
drinks.  This  should  be  supplemented  by  a  mixture  to  be 
given  by  the  mouth,  containing  atropine,  hydrastin, 


29 


450  Narcotic  Drug  Diseases  and  Allied  Ailments. 

capsicum,  and  some  bitter  tonic,  and  this  mixture  can  be 
continued  with  profit  for  two  or  three  weeks. 

The  author  has  found  the  following  formula  to 
answer  the  purpose  well : — 

1$  Atropine  sulphate gr.  %25- 

Hydrastin,  yellow  alkaloid gr.  %0. 

Tincture  of  capsicum iriv. 

Quinine  muriate gr.  j. 

Water   £j. 

Mix  and  make  one  dose;  give  a  dose  similar  to  this  three 
times  a  day. 

After  this  has  been  kept  up  for  about  two  weeks, 
both  this  and  the  strychnine  should  be  discontinued  and 
the  patient  put  on  ichthyol,  which  he  should  continue  to 
take  for  about  a  month. 

The  catarrhal  condition  of  the  stomach  is  the  remain- 
ing disorder  which  would  exert  the  greatest  influence 
toward  a  return  to  the  old  habit,  because  of  its  effects 
in  impairing  digestion. 

Fortunately,  catarrh  of  the  stomach  yields  readily  to 
treatment  in  these  cases  after  alcohol  has  been  discon- 
tinued, but  active  treatment  for  this  disorder  is  essential, 
and  it  should  be  continued  until  all  trace  of  it  has  disap- 
peared and  the  patient's  digestion  is  perfect.  He  should 
be  able  to  eat  and  enjoy  three  good  meals  a  day. 

Patients  of  this  class  need  the  strength  derived  from 
a  hearty  breakfast  to  take  the  place  of  the  support  they 
formerly  received,  or  thought  they  received,  from  the 
alcoholic  drinks.  No  part  of  the  treatment  is  of  greater 
importance  than  this,  since,  if  it  is  not  successfully 
carried  out,  the  patient  will  not  be  so  secure  from  relapse 
as  he  should  be.  Impaired  digestion,  with  its  attendant 
lack  of  strength,  operates  as  an  ever-present  influence 


Alcoholism,  Details  of  Treatment.  451 

suggesting  the  need  of  some  stimulant,  some  outside 
supportive,  and  this  amounts  to  an  autosuggestion  to 
take  a  drink.  This  is  a  dangerous  condition  for  the 
patient  to  be  left  in. 

Ichthyol  meets  this  indication  more  perfectly  than 
anything  else  has  done  in  the  author's  hands. 

Ichthyol  is  said  to  be  an  alterative,  an  antiseptic,  and 
a  vasoconstrictor,  but  neither  of  these  properties,  nor  all 
of  them,  seem  to  fully  account  for  its  action.  The 
author's  use  of  it,  to  a  large  extent,  is  empirical,  but  is 
based  on  his  own  clinical  experience. 

About  thirteen  years  ago  the  writer's  attention  was 
directed  to  ichthyol  in  the  treatment  of  tuberculosis  by 
reading  an  abstract  of  an  article  by  a  German  writer. 
This  article  reported  the  treatment  of  65  cases  of  tuber- 
culosis with  ichthyol,  given  internally  in  doses  of  from 
10  to  15  grains  three  to  six  times  per  day.  The  results 
were  so  much  more  favorable  than  the  results  of  other 
methods  of  treatment  that  the  author  determined  to  try 
it  in  a  case  then  under  treatment.  This  case  had  resisted 
practically  all  the  then-accepted  methods  of  treatment. 
The  patient  had  had  fever  for  more  than  six  months  and 
was  declining  rapidly  in  spite  of  the  most  active  treat- 
ment. Ichthyol  was  obtained  and  a  oo  capsule  full  given 
three  times  a  day. 

The  treatment  the  patient  had  been  on  was  continued 
for  ten  days  in  connection  with  the  ichthyol,  but  by  that 
time  a  distinct  improvement  in  her  condition  was  notice- 
able. She  was  taking  food  more  liberally  and  with 
relish.  At  this  time  all  the  other  medicines  were  dis- 
continued and  ichthyol  alone  was  given  from  that  time 
on. 

It  had  been  almost  impossible  to  get  the  patient  to 
take  nourishment  enough  to  sustain  her  strength,  but 


452  Narcotic  Drug  Diseases  and  Allied  Ailments. 

within  two  weeks  from  the  time  of  beginning  the 
ichthyol  all  the  food  which  was  thought  prudent  to  allow 
was  taken  with  relish  and  more  was  wanted  and  this  was 
digested  and  assimilated  without  difficulty.  There  was 
a  persistent  decline  in  the  temperature  until  the  normal 
was  reached  in  about  six  weeks  and  the  fever  did  not 
recur  after  that. 

In  a  few  weeks  the  patient  was  able  to  be  up  most 
of  the  day  and  convalescence  was  more  rapid  from  that 
time  on.  In  the  course  of  three  or  four  weeks  from  the 
time  of  beginning  the  ichthyol  she  was  allowed  all  the 
food  she  wanted,  and  it  was  surprising,  as  well  as  de- 
lightful, to  see  how  much  she  could  eat  and  digest  with- 
out the  slightest  discomfort  from  it.  She  gained  flesh 
and  strength  rapidly  and  in  six  months  was  in  good 
health,  and  has  remained  well  from  that  time  until  the 
present  writing. 

This  experience  led  the  author  to  try  ichthyol  in  other 
cases  and  during  that  year  16  cases  of  tuberculosis  were 
treated  with  it  with  better  results  than  any  other  line 
of  treatment  had  ever  yielded  in  his  hands.  The  one 
uniform  and  really  remarkable  effect  was  shown  in  the 
prompt  restoration  of  the  appetite,  accompanied  by  the 
ability  of  the  patient  to  eat  almost  anything  in  liberal 
quantities  and  to  digest  and  assimilate  it  perfectly.  In- 
testinal fermentation  and  diarrhea,  so  often  seen  under 
forced  eating,  were  entirely  absent  in  cases  in  which  the 
ichthyol  was  given. 

The  power  of  the  ichthyol  to  increase  the  appetite 
and  to  promote  digestion  and  assimilation  of  the  food, 
with  rapid  increase  in  weight,  led  the  author  to  make 
use  of  it  as  a  flesh  builder  and  an  appetizer  in  all  condi- 
tions where  such  a  remedy  was  indicated,  and  this  use 
has  been  attended  by  most  satisfactory  results. 


Ichthyol  in  Alcoholism.  453 

In  the  treatment  of  chronic  catarrh  of  the  stomach 
of  alcoholics  the  author  formerly  depended  upon  hy- 
drastin  or  berberine  with  petroleum  emulsion,  but,  while 
these  are  excellent  remedies,  they  are  so  much  inferior 
to  ichthyol  that  they  are  not  in  any  sense  to  be  compared 
with  it. 

The  power  of  ichthyol  to  contract  dilated  capillaries 
when  applied  locally  to  a  mucous  membrane  has  been 
long  known,  and  the  author  is  of  the  opinion  that  this, 
probably,  accounts  to  some  extent  for  the  happy  effect  it 
has  on  the  catarrhal  conditions  of  the  stomach  in  alco- 
holic cases.  Whether  this  be  the  explanation  of  its 
action  or  not,  the  author  cannot  say,  but  from  his  wide 
clinical  experience  with  it  he  is  able  to  say  that  it  meets 
the  indications  in  these  cases  most  perfectly;  in  fact,  so 
perfectly  that  he  does  not  hope  for  anything  better. 

Patients  object  to  taking  ichthyol  for  a  few  days, 
because  of  the  sulphurous  eructations  from  it,  but  its 
antiseptic  effect  arrests  all  fermentation  in  the  stomach 
within  three  or  four  days  from  the  time  its  use  is  begun, 
if  taken  regularly,  and  then  it  is  no  longer  objectionable. 
There  is  no  advantage  in  putting  it  in  capsules,  because 
the  eructations  are  the  disagreeable  part  of  its  effects 
and  these  occur  just  as  badly  if  the  remedy  is  given  in 
capsules  as  if  given  in  solution ;  therefore,  the  author  has 
long  since  abandoned  any  effort  to  give  it  in  that  way. 

It  is  best  used  in  a  25  per  cent,  solution  and  this 
should  be  still  further  diluted  when  it  is  given.  A  25 
per  cent,  solution  at  times  proves  to  be  irritating  to  the 
throat,  but  if  diluted  with  a  swallow  or  so  of  water  this 
does  not  occur.  Cinnamon  water  disguises  the  taste  to 
a  greater  degree  than  any'  of  the  other  aromatic  waters. 

The  following  formula,  usually  employed  by  the 
author,  has  been  the  most  satisfactory  in  his  hands : — 


454  Narcotic  Drug  Diseases  and  Allied  Ailments. 

^  Ichthyol  (Merck  &  Co.'s) £j. 

Garantose, 

Soda  bicarbonate aa  gr.  iv. 

Aquae   cinnamomi    gij. 

Aquae  pura   q.  s.  ad  £iv. 

M.  et  ft.  sol.     Write,  teaspoonful  before  each  meal. 

The  garantose  (saccharin),  I  grain  to  the  ounce  of 
mixture,  sweetens  it  just  sufficiently  to  take  away  the 
bitter  taste,  and  the  soda  is  added  to  render  the  garantose 
soluble;  otherwise,  these  ingredients  have  no  value  in 
the  prescription. 

The  indications  to  be  met  in  some  cases  of  alcoholism 
are  simple,  and  the  treatment  can  be  easily  carried  out, 
while  in  others  they  are  so  complicated  that  the  resources 
of  the  best-equipped  institutions,  as  well  as  the  skill  of 
the  most  resourceful  physician,  will  be  taxed  to  the 
utmost;  but  with  the  aid  afforded  by  a  well-equipped 
institution,  a  competent  physician  can  effect  as  large  a 
percentage  of  cures  in  cases  of  chronic  alcoholism  as  can 
be  effected  in  any  other  serious  ailment. 

The  most  skillful  physician  cannot  treat  patients 
successfully  at  their  homes.  The  disadvantage  due  to 
their  home  surroundings  and  the  lack  of  complete  con- 
trol over  the  patient  will  defeat  his  best  efforts.  Even  a 
general  hospital  does  not  assure  the  physician  such  con- 
trol of  the  patient  and  protection  from  outside  intrusion 
as  this  class  of  patients  require. 

Entire  control  of  the  patient  and  his  surroundings  is 
the  first  essential  in  the  successful  treatment  of  a  case  of 
alcoholism.  Under  the  dominating  influence  of  alcohol 
the  patient  cannot  be  expected  to  exercise  self-control 
or  restrain  himself  in  the  use  of  alcoholic  drinks ;  there- 
fore to  succeed,  others  must  be  in  a  position  to  think  and 
act  for  his  best  interest. 


Mental  Attitude  of  Patient  Important  Factor.          455 

Patients  who  have  become  accustomed  to  the  use  of 
alcohol  feel  that  it  is  their  best  friend;  in  fact,  the  only 
remedy  that  gives  them  relief  from  the  intense  nervous- 
ness which  develops  when  they  attempt  to  leave  it  off, 
and  this  fear  of  being  deprived  of  it,  as  much  as  the 
physical  suffering  attending  its  disuse,  leads  them,  if 
necessary,  to  resort  to  all  kinds  of  expedients  to  supply 
themselves  with  it. 

But  when  the  patient  is  assured  that  his  drinks  will 
not  be  discontinued  at  once,  but  will  be  given  to  him  as 
his  condition  demands,  and  this  assurance  is  faithfully 
kept,  he  is  soon  led  to  have  implicit  confidence  in  the 
physician  and  in  his  ability  to  successfully  carry  him 
through  the  trying  ordeal. 

If  the  patient  has  reached  such  a  state  in  the  use  of 
alcohol  as  to  realize  that  he  cannot  himself  abandon  its 
use  he  is  in  a  much  more  favorable  condition  to  begin 
treatment,  since  it  is  very  difficult  to  help  a  man  do,  to 
any  advantage,  what  he  feels  entirely  able  to  do  himself. 
Still  it  is  impossible  at  times  to  bring  drinking  men  to 
admit  that  they  cannot  quit  the  use  of  alcohol  themselves, 
and,  yet,  the  author  would  not  advise  postponing  treat- 
ment until  they  reach  that  mental  state,  because  such 
postponement  might  lead  to  too  much  delay  and  to  their 
ultimate  and  utter  ruin. 

But  if  the  patient  has  reached  the  conclusion  that  he 
is  in  deeper  water  than  he  can  wade  through  successfully 
alone,  and  voluntarily  seeks  the  aid  of  the  physician  or 
an  institution  to  help  him  out  of  his  difficulty,  he  is  in  a 
very  much  more  favorable  condition  to  make  that  under- 
taking a  success  than  had  he  not  reached  that  conclusion ; 
and,  the  final  results  of  the  treatment  are  likely  to  be 
more  satisfactory.  When  a  man  has  reached  such  a 
conclusion  as  this  he  is  ready  to  lay  down  his  business 


456  Narcotic  Drug  Diseases  and  Allied  Ailments. 

and  enter  upon  the  real  work  of  securing  his  freedom 
from  a  dominating,  enslaving  master  with  a  singleness 
of  purpose  that  makes  success  readily  attainable. 

The  facilities  of  a  well-equipped  institution  render 
the  complete  emancipation  of  a  patient  who  has  reached 
this  mental  state  a  comparatively  easy  matter.  The 
patient  should  be  away  from  home  and  free  from  all 
business  cares,  as  the  matter  of  taking  treatment  and 
being  cured  of  alcohol  addiction  is  a  business  sufficiently 
great  and  absorbing  to  require  the  entire  time,  attention, 
and  energy  of  anyone;  they  cannot  do  this  successfully 
while  trying  to  continue  business  or  do  anything  else. 
It  is  of  sufficient  importance  to  justify  any  man  in  leav- 
ing home  and  business,  and  only  in  that  way  can  satis- 
factory results  be  obtained. 

It  is  not  best  for  him  to  undertake  the  matter  as  a 
secret.  One  who  would  accomplish  any  great  end  in 
life,  as  a  rule,  does  not  go  about  it  secretly.  Then,  again, 
the  fact  of  his  drinking  is  publicly  known,  practically,  in 
every  case,  and  it  is  well  for  him  to  commit  himself  openly 
to  a  different  type  of  life.  If  he  slips  away  secretly, 
is  treated,  and  drops  back  into  his  old  ruts  and  with 
his  old  associates,  they  know  nothing  of  it  and,  of  course, 
will  have  made  no  change  in  their  conduct  toward  him ; 
therefore,  they  will  expect,  and  will  insist,  upon  his  con- 
tinuing his  former  life.  Whereas  if  they  know  he  has 
gone  away  to  secure  relief  from  the  distressing  condition 
into  which  this  irregular  and  dissipated  life  has  brought 
him,  if  they  are  his  friends  at  all,  they  will  co-operate 
with  and  support  him  in  the  new  position  he  has  taken. 
Therefore,  instead  of  their  influence  being  such  as  to 
drag  him  down  and  lead  him  to  resume  his  former  haunts 
and  habits,  it  will  be  used  to  encourage  and  sustain  him. 

Then,  again,  a  man's  own  pride  of  character  and 
self-respect  are  involved.  He  does  not  like  to  have  it 


"  Advantages  of  Institutional  Treatment.  457 

said  that  he  has  failed  in  anything  he  has  undertaken. 
Therefore,  if  it  is  known  that  he  has  gone  away  and 
taken  treatment  for  alcoholism  and  has  fully  committed 
himself  to  that  undertaking,  his  own  pride  of  character 
will  lead  him  to  do  the  very  best  he  can  to  make  a  perma- 
nent success  of  it.  Whereas,  had  he  merely  taken  treat- 
ment at  home,  or  slipped  away  secretly  and  taken 
treatment,  without  the  matter  being  known,  these  in- 
fluences to  support  him  would  not  be  present,  and  he 
would  be  more  likely  to  return  to  the  use  of  alcohol. 

The  mental  attitude  of  the  patient  in  any  undertaking 
is  an  important  one,  but  in  this  it  is  far  more  important 
than  in  ordinary  affairs.  The  more  fully  the  patient 
commits  himself  to  the  undertaking,  the  better  results 
will  follow.  This  is  shown  in  the  practice  of  almost  every 
physician  in  cases  where  they  are  called  upon  to  sober  up 
and  to  treat  alcoholic  patients  at  their  homes.  A  man 
has  been  drinking  and  has  gotten  into  a  bad  way,  is 
unable  to  go  to  his  business,  and  sends  for  his  physician. 
The  physician  visits  his  home  and  treats  him  for  a  few 
days,  getting  him  back  on  his  feet,  and  probably  may 
have  given  all  medicines  that  would  really  be  indicated 
as  therapeutic  agents ;  yet,  the  patient  looks  upon  it  as  a 
mere  expedient  and  does  not  commit  himself  fully  to  the 
business  of  abandoning  the  use  of  alcohol ;  therefore,  he 
gets  up  with  a  feeble  mental  resolve  to  leave  it  alone,  and 
this  resolution  does  not  prove  sufficiently  strong  and 
abiding  to  control  his  conduct,  and  in  a  few  weeks  he  is 
again  found  indulging  his  appetite. 

No  permanent  results,  so  far  as  the  cure  of  the  addic- 
tion is  concerned,  grow  out  of  such  an  experience.  Even 
if  the  physician  understood  these  conditions  perfectly 
and  undertook  to  make  the  treatment  so  thorough  as  to 
effect  a  real  cure  of  the  addiction,  he  will  find  himself 


458  Narcotic  Drug  Diseases  and  Allied  Ailments. 

unable  to  keep  the  patient  away  from  business  long 
enough  to  make  a  success  of  the  undertaking.  The 
author  would  not  now  undertake  the  treatment  of  any 
alcoholic  under  his  home  surroundings  and  would  not 
advise  anyone  else  to  do  so. 

The  author  does  not  feel  that  he  should  close  this 
chapter  without  a  warning  against  any  institution  or 
physician  offering  to  send  a  home  treatment  for  alco- 
holics or  drug  victims.  Such  an  undertaking  is  worse 
than  folly,  and,  when  a  proposition  of  that  kind  does 
not  spring  from  entire  ignorance  of  the  conditions  to  be 
met,  it  is  prompted  by  criminal  avarice.  Especially 
fraudulent  is  the  offer  to  send  a  remedy  that  can  be 
administered  in  coffee,  etc.,  without  the  patient's  knowl- 
edge, and  thus  overcome  the  desire  for  liquor  and  break 
up  the  habit. 

THE  THREE-DAY  LIQUOR  CURE. 

The  time  required  for  the  successful  treatment  of  a 
case  of  chronic  alcoholism  varies  from  two  weeks  to  two 
months.  Those  who  promise  to  effect  a  cure  in  much 
shorter  time  than  that,  promise  more  than  they  can 
perform.  A  "three-day  liquor  cure"  is  being  advertised 
extensively  throughout  the  country,  and  a  number  of 
institutes  have  recently  been  opened  for  the  employment 
of  this  method. 

This  treatment  consists  of  the  administration  of  a 
dose  of  cathartic  pills  and  after  that  the  hourly  adminis- 
tration of  an  emetic  in  liquid  form,  the  emetic  consisting 
of  either  lobelia  or  ipecac  or  of  the  two  combined.  An 
hour  and  a  half  from  the  time  of  giving  the  first  dose 
of  the  emetic,  the  patient  is  required  to  take  a  drink  of 
whatever  alcoholic  liquor  he  has  been  using  and  this  is 
repeated  every  half-hour  until  four  drinks  have  been 


The  Three-day  Liquor  Cure.  459 

taken.  All  of  these  are  promptly  given  over  to  the 
slopjar  with  interest. 

The  liquid  emetic  is  kept  up  every  hour  for  the  first 
day,  but  only  the  four  drinks  are  offered  to  the  patient. 
If  he  asks  for  more  liquor,  it  is  given  and  this  is  followed 
by  an  extra  large  dose  of  the  emetic,  sufficient  to  insure 
immediate  and  prolonged  vomiting.  The  second  and 
third  days'  treatment  are  the  same,  only  the  emetic  is 
given  at  less  frequent  intervals,  and  only  two  drinks  are 
required  to  be  taken  on  the  second  day.  If  the  patient 
asks  for  more  on  that  or  on  the  third  day,  it  is  given,  and 
this  is  followed  by  a  double  dose  of  the  emetic. 

The  extreme  nausea  and  vomiting  from  this  course, 
if  the  patient  can  be  made  to  take  it,  is  supposed  to  dis- 
gust him  so  completely  with  whisky  that  he  will  not  take 
it  again.  By  the  time  he  has  been  kept  in  this  condition 
for  three  days,  he  is  so  disgusted  with  whisky,  himself, 
and  everything  else  that  an  effort  to  swallow  anything 
will  cause  him  to  vomit.  It  is  true  that  he  does  not  want 
whisky,  because  he  is  not  in  condition  to  take  and  retain 
anything,  but  he  is  no  more  cured  of  the  whisky  habit 
than  he  would  have  been  had  he  drank  until  his  stomach 
rebelled  and  he  had  vomited  three  days  and  nights  from 
the  effects  of  whisky. 

His  system  is  still  in  a  badly  disordered  condition ;  he 
is  extremely  nervous  and  cannot  sleep,  is  totally  unfit  for 
business,  and  if  he  recovers  it  is  because  of  the  restora- 
tive forces  of  the  system  and  not  because  of  any  curative 
effect  the  treatment  had  on  him.  Such  sleight-of-hand 
fake  methods  cannot  be  too  strongly  condemned.  There 
is  no  curative  value  in  them  and  the  public  should  be 
taught  to  avoid  them. 

In  undertaking  the  treatment  of  alcoholic  patients, 
the  physician  should  take  a  comprehensive  view  of  the 


460  Narcotic  Drug  Diseases  and  Allied  Ailments. 

patient  and  his  surroundings  and  endeavor  to  estimate 
correctly  every  influence  which  has  in  any  way  con- 
tributed to  his  enslavement,  and  to  direct  the  life  of  the 
patient  thereafter  so  as  to  remove  every  one  of  the 
hurtful  influences,  as  far  as  is  possible. 

The  physical  man  must  be  completely  renovated  and 
every  function  of  the  body  restored  to  normal  activity. 

The  mental  bias  favorable  to  the  use  of  alcoholic 
liquors  must  be  eradicated  and  in  its  stead  a  positive 
aversion  to  alcohol  must  be  established. 

The  patient  is  to  be  given  a  new  chance  in  life  by 
being  put  on  his  feet  with  a  clear  head,  in  full  control 
of  all  his  faculties,  and  free  from  the  dominating  influ- 
ence of  alcohol.  The  consummation  of  such  a  work  is 
certainly  worthy  of  the  best  efforts  of  any  man. 


CHAPTER  XXIV. 

CHRONIC  ALCOHOLISM  A  DISEASE: 
ITS  CURABILITY. 

THAT  the  author's  views  as  to  alcoholism  being  in 
reality  a  disease,  and  that  the  same  is  curable  by  treat- 
ment, may  not  be  considered  extreme  or  out  of  harmony 
with  the  most  approved  teachings  of  the  day,  extracts 
from  the  writings  of  leading  men  engaged  in  the  study 
and  treatment  of  inebriety  are  given  in  the  following 
pages. 

Norman  Kerr,  London,  in  his  work  on  "Alcoholism," 
says : — 

"WHAT  SHALL  WE  Do  WITH  THEM  ? 

"Such  are  our  diseased  habitual  drunkards.  What  are  we  to 
do  with  them  ?  Some  reply,  'Drunkenness  is  a  vice.  Let  them  kill 
themselves;  why  should  they  not?  and  the  sooner  the  better.' 
How  such  an  answer  could  be  given,  how  such  a  line  of  conduct 
could  be  defended  in  this  nineteenth  century  of  the  Christian  era, 
is  utterly  beyond  my  comprehension.  Let  the  beginning  of  the 
hapless  victim's  intemperance  have  been  in  thoughtless  abandon- 
ment to  a  dangerous  pastime,  in  selfish  indulgence  in  a  vicious 
habit,  or  in  criminal  dalliance  with  an  unlawful  pleasure,  as  he 
crouches  at  my  feet,  and  with  palpitating  heart  and  quivering 
tongue,  implores  me  to  save  him  from  himself,  if  I  could  turn 
coldly  away  and  bid  him  go,  die,  and  make  a  speedy  ending  on't, 
I  could  but  look  upon  myself  as: — 

"'A  stony  adversary,  an  inhuman  wretch, 
Uncapable  of  pity,  void  and  empty 
From  any  dram  of  mercy.' 

(461) 


462  Narcotic  Drug  Diseases  and  Allied  Ailments. 

"It  may  be  in  strict  accordance  with  the  stern  decree  of 
justice,  though  I  doubt  it,  to  leave  the  unhappy  victim  to  his  fate 
and  raise  not  a  hand  to  stay  the  arm  upraised  to  bear  the  poisoned 
chalice  to  the  mouth.  It  may  be  just,  though  I  more  than  doubt 
it,  for  those  who,  with  a  healthy  brain  and  strong  will,  aided  by 
intellectual,  moral,  religious,  and  social  restraints,  having  been 
preserved  from  falling  under  the  sway  of  that  devouring  appe- 
tite to  which  a  diseased  brain,  a  feeble  will  or  a  hereditary 
predisposition  through  the  poisoned  body  and  brain  of  one  or 
both  parents,  has  rendered  others  an  easy  prey,  to  pass  by  on  the 
other  side  and  leave  the  drunken  slave,  with  no  hope  but  the 
grave,  to  his  chains,  his  wretchedness,  and  his  despair.  But  is  it 
right?  Let  us  treat  the  despairing  captives  of  alcohol  as  we  our- 
selves have  been  treated — let  us  deal  with  them  as  we  have  been 
dealt  by — let  us  temper  our  justice  with  that  compassion  to  which 
we  owe  so  much — let  us  be  just,  but  too,  be  merciful. 

"  'Why  all  the  souls  that  were  forfeit  once ; 
And  He  that  might  the  vantage  best  have  took 
Found  out  the  remedy.     How  would  you  be 
If  He,  which  is  the  top  of  judgment,  should 
But  judge  you  as  you  are?    Oh,  think  on  that, 
And  mercy  then  will  breathe  within  your  lips, 
Like  man  new  made.' 

"But  it  has  been  urged  that  the  cure  of  the  habitual  drunkard 
is  hopeless.  Were  it  so,  the  enterprise  is  yet  lofty,  the  under- 
taking noble.  Could  we  do  no  more  than  snatch  the  victim  for  a 
time  from  his  persecutor  and  restore  him  to  tolerable  health  and 
strength,  to  such  health  and  strength  that  if  he  only  keeps  the 
enemy  at  bay  by  totally  abstaining  he  will  be  permanently  cured, 
we  should  achieve  something  well  worth  trying  for.  The  diffi- 
culty of  an  undertaking  is  no  reason  why  we  should  not  attempt 
its  accomplishment,  and  hard  though  the  task  may  be,  we  have 
much  to  encourage  us.  The  possibility  of  the  permanent  reforma- 
tion and  cure  of  habitual  drunkenness  has  now  been  placed 
beyond  dispute  by  a  great  company  and  cloud  of  witnesses. 


Even  Bad  Cases  Curable.  463 

"EVEN  BAD  CASES  OF  INEBRIETY  ARE  CURABLE. 

"A  few  years  ago  a  magistrate's  clerk  in  the  metropolis  is 
reported  to  have  declared,  in  the  course  of  a  trial  involving  the 
character  for  temperance  of  one  of  the  witnesses,  'Everybody 
knows  that  teetotalers  are  nearly  all  reformed  drunkards.'  Were 
this  true  it  would  indeed  be  a  magnificent  result,  as  it  is  generally 
conceded  that  there  are  more  than  4,000,000  of  adult  water- 
drinkers  in  the  realm;  but  though  I  fear  we  cannot  claim  any- 
thing like  so  great  a  triumph,  I  have  no  hesitation  in  saying  that 
I  am  within  the  mark  when  I  aver  that  a  quarter  of  a  million  of 
human  souls  have  in  this  country  alone  been  raised  from  drunken 
death  to  abstaining  life. 

"I  have  myself  known  of  the  cure  of  what  seemed  to  be 
absolutely  and  hopelessly  incurable  cases,  and  my  own  efforts  in 
the  cause  of  abstaining  temperance  have  taught  me  that  no  case 
is  utterly  hopeless  and  wholly  beyond  remedy,  so  that  I  will  never 
despair  of  the  rescue  of  anyone,  no  matter  how  shattered  his 
nerves,  or  how  weak  his  resolves,  or  though  he  be: — 
"  'A  creature  unprepared,  unmeet  for  death.' 

"In  the  long  roll  of  temperance  worthies  will  be  found  the 
names  of  many  a  brand  plucked  from  the  burning,  and  no  con- 
queror of  ancient  or  modern  times  can  boast  of  so  numerous  and 
glorious  an  array  of  hard-won  trophies  as  can  the  great  total 
abstinence  movement,  wherever  with  true  Christian  fervour  it  has 
raised  its  triumphant  banner  aloft." 

B.  C.  Keister,  Richmond,  Va.,  says  (Senate  Docu- 
ment No.  48,  1909)  : — 

"We  also  find  by  clinical  and  microscopic  observation  that 
by  the  constant  but  moderate  use  of  alcohol  a  hardening  of  the 
walls  of  the  blood  vessels,  which  is  soon  followed  by  a  thickening, 
due  to  an  increase  of  fibrous  tissue,  which  leads  to  a  lack  of 
normal  elasticity  and  contractility  on  the  part  of  the  vessel  walls. 


464  Narcotic  Drug  Diseases  and  Allied  Ailments. 

We  then  have  a  delay  in  the  blood  current,  and  finally  a  stagnation 
or  stasis  of  the  circulation.  This  condition  may  occur  in  any  part 
of  the  body  or  in  any  of  the  organs,  and  is  known  to  physicians 
as  fibrous  or  fatty  degeneration. 

"With  this  abnormal  condition  of  the  blood  vessels  in  the 
brain,  we  may,  on  the  slightest  provocation,  such  as  a  sudden 
fright,  a  hearty  meal,  or  anything  that  may  cause  undue  agitation 
of  the  heart,  have  a  rupture  of  a  blood  vessel,  followed  by  paraly- 
sis or  apoplexy.  With  this  condition  of  the  blood  vessels  of  the 
liver  and  kidneys,  we  may  have  such  a  change  in  the  functions 
of  these  organs  as  will  give  rise  to  symptoms  that  are  equally  as 
alarming. 

"These  pathological  conditions,  according  to  microscopic  in- 
vestigation, are  brought  about  by  no  other  cause,  old  age  excepted, 
than  alcoholic  drinking. 

"It  is  a  true  saying  that  'a  man  is  no  older,  no  younger,  and 
no  stronger  than  his  blood  vessels.' 

"We  have  a  most  deplorable  condition  of  the  vessels,  the 
cells,  and  walls  of  the  stomach  in  persons  addicted  to  the  moderate 
use  of  alcohol,  giving  rise  to  the  many  and  varied  symptoms  of 
effects  of  alcohol  on  the  pepsin  of  the  gastric  juice.  It  is  claimed 
that  i  grain  of  alcohol  is  capable  of  destroying  800  grains  of 
pepsin. 

"One  of  the  well-known  characteristics  of  alcohol  is  its  power 
to  extract  water  from  any  object  with  which  it  comes  in  contact; 
hence  its  deleterious  effect  on  the  blood  corpuscles,  which  contain 
79  per  cent,  of  water;  also  the  gastric  juice,  which  contains  97 
per  cent,  of  water;  the  pancreatic  juice,  which  contains  90  per 
cent,  water;  the  saliva,  which  contains  99  per  cent,  water;  bile, 
87  per  cent,  water;  muscle,  75  per  cent,  water;  brain,  80  per 
cent,  water,  etc.  It  extracts  the  moisture  from  the  5,000,000  little 
cells  that  supply  the  gastric  juice  to  the  stomach  and  destroys  the 
protoplasm  of  the  epithelial  cells  of  the  lining  of  the  stomach,  and 
in  so  doing  the  functions  of  this  important  organ  of  digestion  are 


Alcoholism,  Structural  Lesions  in.  465 

almost  obliterated.  We  find  that  the  entire  alimentary  canal  is 
more  or  less  affected  by  this  same  destructive  process;  in  fact, 
no  part  of  the  human  structure  escapes  the  destructive  influence 
of  this  insidious  enemy. 

"The  brain  and  nerves  being  of  a  watery  character  (80  per 
cent,  water)  renders  them  very  susceptible  to  the  influence  of 
alcohol.  The  microscope  shows  that  grave  alterations  take  place 
in  the  protoplasm  of  both  the  nerve  cell  and  fiber  under  the  action 
of  alcohol  after  it  has  been  freely  taken  for  some  time.  It  is  a 
well-known  fact  that  alcohol  is  a  powerful  protoplasmic  poison, 
it  having  a  special  selective  affinity  for  the  delicate  cells  of  the 
brain  and  nervous  system,  with  whose  function  and  capacity  it 
interferes  even  at  a  very  early  stage,  and  finally  causing  perma- 
nent gross  alterations  in  the  tissue  which  are  demonstrable  to  both 
the  naked  eye  and  through  the  microscope.  A  cell  damaged  in 
this  way  never  recovers.  It  has  been  demonstrated  by  clinical 
observation  that  alcohol  has  been  found  pent  up  in  small  sacs  on 
the  brain  in  persons  who  have  been  chronic  drinkers.  It  may  be 
found  in  various  quantities.  'Enough  alcohol  has  been  repeatedly 
found  in  the  brain  of  a  dead  toper  to  spoon  out  into  an  open  dish 
and  set  on  fire.'  We  may  have,  as  a  result  of  this  accumulation 
of  alcohol,  pressure  on  the  brain  substance,  giving  rise  to  such 
diseases  as  apoplexy,  epilepsy,  delirium,  and  insanity.  The  brain 
is  hardened  by  the  alcohol  on  account  of  its  power  of  absorbing 
the  water  therefrom,  causing  a  very  marked  disturbance  in  the 
transmission  of  thought  and  nerve  force,  impairing  to  a  certain 
extent  all  the  mental  faculties.  When  we  consider  these  patho- 
logical conditions  of  the  brain  and  nerves,  wrought  by  alcohol,  is 
it  any  wonder  that  we  have  such  an  increase  of  nervous  diseases, 
insanity,  epilepsy,  feeble-mindedness,  both  hereditary  and  ac- 
quired ?" 

Charles    "A.    Rosenwasser,    Newark,    N.    J.,    says 
(Senate  Document  No.  48,  1909)  :— 

80 


466  Narcotic  Drug  Diseases  and  Allied  Ailments. 

"Doctor  Day,  for  many  years  head  of  the  Washington! an 
Home,  Boston,  an  institution  now  in  the  fifty-second  year  of  its 
existence,  made  a  study  of  8000  cases  that  had  been  under  treat- 
ment and  found  over  30  per  cent,  sober  and  temperate.  He 
says : — 

"  'Twenty-two  years  of  experience  in  this  work  has  taught  me 
that  the  task  is  neither  hopeless  nor  thankless ;  nor  would  it  be  if 
the  measure  of  success  had  been  lessened  one-half  from  the 
known  rate  of  percentage  of  cures.' 

"Progressive  Switzerland  has  long  since  learned  that  inebriety 
is  a  curable  disease  and  that  it  pays  to  maintain  a  hospital  for  the 
purpose.  At  Ellikon,  near  Zurich,  there  has  existed  such  a 
hospital  for  the  past  nineteen  years.  The  result  of  its  labors  is 
most  encouraging  and  proves  conclusively  that  the  treatment  of 
inebriety  has  long  since  passed  the  experimental  stage. 

"At  Knoxville,  Iowa,  there  has  been  in  existence  for  the 
past  three  years  a  state  hospital  for  inebriates,  and  the  results 
thus  far  are  very  satisfactory.  From  the  second  biennial  report 
of  this  institution  we  learn  that  of  the  entire  number  of  patients 
treated  (774)  41%  per  cent,  are  known  to  be  cured  and  living  up 
to  the  conditions  of  their  parole. 

"Minnesota  has  also  taken  the  proper  step  in  this  matter, 
and  last  year  established  a  farm  for  inebriates.  Surely  the 
knowledge  of  the  excellent  results  obtained  in  the  above-men- 
tioned institutions,  as  well  as  the  results  obtained  in  the  great 
number  of  private  and  public  institutions  for  the  care  and  treat- 
ment of  inebriates  in  this  country  and  abroad,  ought  to  convince 
the  most  skeptical,  and  should  serve  as  a  great  stimulus  in  our 
efforts  to  overcome  the  obstacles  which  we  encounter  in  the  path 
of  rational  treatment  of  the  inebriate,  and  there  are  many  obstacles 
to  be  overcome." 

Howard  A.  Kelly  says  (Senate  Document  No.  48, 
1909) :— 


Moderate  Drinking  Extremely  Dangerous.  467 

"Those  who  drink  constantly  in  so-called  'moderation'  often 
develop  alarming  symptoms,  in  time  associated  with  diseases  of  a 
degenerative  character  affecting  in  the  lines  of  least  resistance 
one  or  other  of  the  great  vital  organs  of  the  body.  In  operations 
these  factors  demand  careful  consideration.  In  the  prognosis 
they  are  as  a  rule  more  important  than  any  other  factor;  a  habit 
of  'moderate'  or  excessive  drinking  lowers  the  vitality  and  lessens 
the  reparative  powers,  so  that  serious  postoperative  complications 
are  likely  to  follow  and  interrupt  or  even  cut  short  the  con- 
valescence in  such  cases. 

"One  of  the  most  alarming  effects  is  that  observed  in  the 
arterial  walls  and  in  the  heart  muscle,  which  are  weakened.  The 
impairment  of  nutritive  processes  is  another  pronounced  factor. 
All  rational  surgery  and  treatment  of  disease  takes  into  serious 
account  the  question  of  the  use  of  alcohol  by  the  patient.  This  is 
science  and  not  sentiment  or  theory.  .  .  . 

"One  of  the  greatest  lessons  life  has  taught  me  is  that  great 
truths  grow  not  stale,  but  sweeter  with  repetition,  so  I  do  not 
hesitate  to  remind  you  of  certain  things,  though  you  know  them. 
I  therefore  pause  a  moment  as  I  approach  my  conclusion  to 
"consider  some  of  the  common  arguments  against  total  abstinence 
urged  by  a  friend  of  mine  a  few  days  since  as  we  discussed  this 
momentous  topic.  First  and  foremost  stands  that  time-honored 
assertion  so  often  heard  on  the  lips  of  the  drunkard,  as  well  as  of 
the  moderate  drinker :  'It  is  a  sign  of  weakness  to  pledge  myself 
to  abstinence.  My  will  is  strong  enough ;  I  can  control  myself ; 
I  can  quit  when  I  will.'  It  seems  to  me,  I  replied  to  my  inter- 
locutor, that  the  best  answers  to  arguments  in  the  realm  of  morals 
are  the  facts,  and  here  they  are  undisputed:  Out  of  all  the 
drunkards  and  the  tens  of  thousands  of  criminals  made  what  they 
are  by  alcoholic  liquors,  of  the  thousands  who  fill  our  insane 
asylums  and  the  tens  of  thousands  of  dependents  in  our  poor- 
houses,  it  would  be  hard  to  find  one  not  equally  assertive  of  the 
sovereignty  of  his  will  in  all  his  acts  and  of  his  entire  ability 


468  Narcotic  Drug  Diseases  and  Allied  Ailments. 

to  take  liquor  or  to  let  it  alone,  as  he  might  choose,  when  he 
started  out. 

"It  is  pitiful  to  hear  now  and  then  even  a  poor,  debauched 
drunkard,  with  one  foot  slipping  over  the  edge  of  the  grave,  still 
reiterating  this  same  old  worn-out  phrase.  I  think  I  still  hear  the 
last  feeble  refrain  as  he  topples  into  the  grave,  'I  can,'  but  all  who 
pitifully  watch  him  know  that  he  can't.  What  a  peculiarly 
damnable  trait  it  is  in  alcohol,  that  while  it  is  literally  destroying 
the  highest  centers  in  the  brain  and  wiping  out  the  fibrils  of  asso- 
ciation so  necessary  to  the  will  in  forming  a  judgment  to  act  or  to 
restrain  it  yet  deludes  its  victim  into  thinking  that  he  has  quick- 
ened powers,  a  stronger  will,  and  a  better  judgment.  Those  are 
interesting  experiments  cited  by  the  Rosanoffs  and  adverted  to 
by  President  Eliot,  of  Harvard,  in  his  paragraphs  in  the  Ladies' 
Home  Journal  (March,  1909)  where  the  typesetters  were  tested 
with  typewritten  copy  under  moderate  drinking  and  after  absti- 
nence, when  it  was  found  that,  while  they  often  thought  they  were 
doing  more  work  under  the  influence  of  the  drug,  in  reality  they 
were  doing  far  less.  It  is  evident  from  these  experiments  that  a 
liquor-imbibing  nation  assumes  a  heavy  handicap  in  the  race  for 
industrial  supremacy. 

"I  hear  the  makers  of  alcohol,  at  last  roused  by  the  prohibition 
wave,  crying  out  that  they  stand  for  its  moderate,  not  for  its 
immoderate,  use. 

"In  reply  to  this  I  answer  that  if  they  make  it  and  sell  it  the 
use  is  practically  beyond  their  control,  and  that  their  plausible 
declarations  are  as  light  as  the  paper  on  which  they  are  written, 
and  can  in  no  way  affect  its  use,  whether  moderate  or  immoderate. 
I  further  inquire  why  these  gentlemen  have  been  so  long  in 
reaching  this  benevolent  conclusion.  I  declare  that  I  believe  their 
contention  and  their  expressed  desires  are  specious  and  false,  and, 
further,  I  aver  that,  judging  by- such  scientific  evidence  as  we  now 
have,  there  is  no  such  thing  as  a  moderate  use  of  alcohol." 


Will-power  Not  Sufficient.  469 

C.  A.  McBride,  M.D,  L.R.C.P.S.  (Edin.),  in  his 
recent  work  on  "The  Modern  Treatment  of  Alcoholism," 
says : — 

"THE  CONSTANT  DRINKER. 

"In  this  division  may  be  placed  all  those  inebriates  whose 
disease  leads  them  into  a  daily  indulgence  in  stimulants.  They 
feel  the  need  of  the  narcotic  upon  awakening  each  morning,  and  as 
the  effect  of  each  drink  wears  off  during  the  day  they  feel  the 
need  of  another,  and  this  condition  persists  throughout  the  days 
of  the  year.  There  is  no  period  of  the  twelve  months  in  which 
they  are  indifferent  to  alcohol,  and  if  from  any  cause  they  are 
deprived  of  it  they  are  conscious  of  a  deficiency  in  their  economy, 
the  absence  of  something  which  they  find  necessary  to  enable  them 
to  act  and  feel  normal.  The  term  normal  is  not  a  correct  one, 
for  no  inebriate  can  possibly  be  normal,  but  it  is  the  only  one 
which  conveys  a  clear  idea  of  how  the  inebriate  feels  when  he 
has  had  just  enough  alcohol  to  steady  his  shaky  hand,  clear  his 
confused  brain,  sharpen  his  appetite  for  food,  and  tone  up  his 
nerves  generally. 

"Deprive  him  of  this  necessary  amount  of  alcohol,  and  he  is 
like  a  piece  of  machinery  working  with  all  the  connections  loose — 
there  is  a  jarring  and  jolting  of  the  whole  machine;  but  stoke  him 
with  the  right  amount  of  alcoholic  fuel,  and  like  the  adjusted 
machine  he  steadies  down,  and  if  the  working  is  not  perfect  at 
least  gives  a  passable  performance.  There  is  no  period  during 
the  whole  year  in  which  the  victim  is  absolutely  free  from 
bondage. 

"He  may  by  the  exercise  of  will-power  or  under  the  influence 
of  some  powerful  motive  cease  to  indulge  for  a  longer  or  shorter 
time,  but  during  the  whole  of  this  period  of  abstinence  he  is  more 
or  less  conscious  of  what  -we  term  craving,  and  although  his 
general  health  may  improve  owing  to  more  regular  habits  in  eating 
and  sleeping,  coupled  with  the  absence  of  the  narcotic,  yet  he  will 
tell  you  that  there  is  a  feeling  of  something  wanting  which  he 


470          Narcotic  Drug  Diseases  and  Allied  Ailments. 

finds  difficult  or  impossible  to  satisfy.  This  is  not  caused  by  the 
mere  cessation  of  a  daily  habit,  although  that  may  in  part  account 
for  his  feelings;  it  is  due  to  something  far  more  deeply  rooted 
than  habit,  for  it  comes  from  the  man's  very  nerve  cells  them- 
selves. 

"It  is  a  real  hunger  of  the  cells,  calling  for  the  narcotic  with 
which  they  have  been  supplied  so  regularly  and  so  long  that  they 
have  ceased  to  provide  for  themselves,  and  have  learned  to  depend 
upon  this  constant  supply.  This  craving  is  an  expression  of  the 
sensory  nerve  cells.  It  is  well  known  that  the  effect  of  coddling 
any  part  of  the  human  system  is  to  make  that  part  less  resistent 
against  the  very  forces  from  which  it  has  been  screened.  An 
unnecessary  amount  of  clothing  worn  makes  the  wearer  less 
resistant  of  cold;  living  in  overheated  rooms  causes  an  undue 
sensitiveness  to  draughts,  etc. 

"So  it  is  with  the  alcoholic.  He  coddles  his  sensory  nerves 
with  the  benumbing  effects  of  alcohol,  and  thereby  lessens  the 
transmission  to  the  brain  centres  of  uncomfortable  sensations 
from  different  parts  of  the  body. 

"He  feels  more  comfortable  because  he  has  cut  the  com- 
munication between  the  brain  and  the  more  or  less  uncomfortable 
parts  beyond.  By  constant  repetition  of  this,  the  sensory  nerve 
cells  become  hypersensitive,  and  when  there  is  a  temporary  with- 
drawal of  the  narcotic  they  are  more  sensitive  to  the  usual 
stimuli,  and  he  feels  what  he  terms  a  craving. 

"He  terms  it  a  craving  because  he  knows  that  alcohol  will 
stop  it  for  a  time,  i.e.,  for  so  long  as  there  is  sufficient  left  in  the 
system  to  benumb  these  cells. 

"In  this  division  of  alcoholics  the  craving  is  present  whenever 
the  supply  is  stopped.  This  craving  is  present  in  many  men  who 
not  only  are  not  aware  of  it  themselves,  but  sincerely  pity  others 
in  whom  they  recognize  its  presence.  Take  the  large  class  of 
city  men  who  transact  business  over  a  glass  of  wine  or  whisky- 
and-soda.  These  drinks  are  repeated  again  and  again  during  the 


Alcoholic  Slavery,  Test  for.  471 

day  as  a  mere  adjunct  to  doing  business.  It  becomes  a  daily 
custom  to  them,  just  as  eating  their  meals. 

"After  this  has  gone  on  for  a  few  years,  tell  one  of  these 
men  that  he  has  become  an  inebriate  and  he  indignantly  protests, 
but  ask  him  to  test  the  matter  by  voluntarily  abstaining  for  a 
month,  and  he  is  surprised  by  finding  himself  possessed  of  a 
craving  for  stimulants. 

"This  is  the  test  I  always  apply  in  such  cases.  If  he  does  not 
miss  the  alcohol  during  the  month  of  abstinence,  and  if  he  finds 
his  nerves  as  steady  without  it  as  with  it,  then  he  has  not  yet 
contracted  the  disease;  but  if,  as  many  do,  he  finds  himself  not 
up  to  the  mark  in  various  ways,  he  is  already  a  victim  and  differs 
from  the  poor  inebriate  whom  he  so  sincerely  pities,  or  maybe 
condemns,  only  in  degree — a  degree  which  time  and  indulgence 
may  rapidly  obliterate. 

"If  any  of  the  many  who  boast  of  their  ability  to  take  alcohol 
daily  without  harm,  and  who  scorn  the  poor  fool  who  cannot  do 
the  same,  will  try  the  simple  test  which  I  have  mentioned,  they 
may  find  a  painful  surprise  in  store  for  them. 

"VOLUNTARY  DRINKERS. 

"The  fourth  class  of  inebriates  are,  strictly  speaking,  not 
medical  cases  at  all.  They  are  the  voluntary  drinkers,  and  for  a 
certain  period  in  their  lives  are  not  afflicted  by  any  craving  for 
alcohol.  In  the  beginning  it  is  not  the  physical  but  the  moral  side 
of  them  which  is  at  fault.  Nevertheless,  as  they  often  eventually 
become  inebriates,  it  is  necessary  to  consider  them  from  a  medical 
point  of  view. 

"The  distinguishing  point  about  them  is  that  they  have  no 
physical  craving  for  alcohol,  and  drink  from  mere  caprice.  If 
asked  to  join  a  drinking  party  they  will  do  so,  and  become  intoxi- 
cated for  the  mere  fun  of  the  thing.  They  drink  in  order  to  get 
drunk,  either  for  the  pleasure  it  gives  them  or  to  forget  their 
trouble  and  sorrow,  and  when  the  occasion  passes  which  caused 


472  Narcotic  Drug  Diseases  and  Allied  Ailments. 

them  to  drink  they  sober  up  entirely  free  from  any  physical 
craving,  and  will  not  drink  again  until  some  special  circumstance 
induces  them  to  do  so. 

"They  can  be  drunk  or  sober  at  will,  provided  they  have  the 
means  to  pay  for  it.  Their  drinking  is  a  mere  vice,  and  it  is 
the  confusion  of  this  class  of  drinkers  with  the  genuine  inebriates 
that  has  caused  so  much  misunderstanding  of  the  whole  question. 
It  is  necessary  to  make  this  point  quite  clear,  namely,  that  there 
are  two  classes  of  drinkers — those  who  get  drunk  from  mere 
vice,  and  those  who  do  so  from  a  need  to  satisfy  a  physical 
craving.  Let  this  be  clearly  understood,  and  the  great  controversy 
which  has  raged  for  ages  and  which  is  still  raging  will  cease,  and 
the  preacher,  the  temperance  lecturer,  the  social  reformer,  and  the 
laity  generally  will  cease  to  hold  diverging  views,  while  the 
genuine  inebriate  will  get  more  consideration  and  suffer  less 
undeserved  persecution  by  the  self-righteous,  uncharitable  critics 
who  pass  judgment  upon  them,  in  their  ignorance.  The  whole 
ground  of  treatment  would  also  be  placed  upon  a  clear  and 
rational  basis.  Millions  of  money  which  is  now  wasted  in  mis- 
guided efforts  would  be  spent  in  a  useful  direction. 

"It  is  only  fair  to  add  that  the  laity  are  not  altogether  to 
blame  in  this  matter,  for  until  recently  only  a  small  proportion 
of  the  medical  profession  understood  the  true  nature  of  inebriety ; 
indeed,  one  can  go  further,  and  say  that  even  to-day  doctors  are 
to  be  found  who  are  still  ignorant  concerning  this  question,  and 
consequently  are  misleading  the  laity.  Magistrates,  from  their 
large  experience  of  such  cases,  are  far  better  informed  upon  the 
subject  than  many  of  our  profession.  Every  specialist  in  inebriety 
knows  that  immeasurable  misery  and  harm  has  been  done,  and  is 
being  done,  through  the  misunderstanding  of  the  facts.  When 
we  come  to  consider  the  question  of  treatment,  I  will  show  how 
this  misunderstanding  works  a  further  immeasurable  harm. 

"The  first  essential  in  the  treatment  of  alcoholism  is  to 
recognize  that  inebriety  is  a  disease.  Unnecessary  as  this  state- 


Routine  Treatment  Not  Successful.  473 

ment  may  seem,  yet  we  find  many  to-day  who  do  not  believe  it, 
and  it  stands  to  reason  that  if  the  doctor  starts  with  the  belief 
that  his  patient  has  no  disease  he  is  not  likely  to  cure  him. 

"Admitting  alcoholism  to  be  a  disease,  it  is  our  duty  as  doctors 
to  find  a  remedy  for  the  complaint.  One  of  the  objects  of  this 
book  is  to  show  that  such  a  remedy  has  been  found,  and  in  what 
cases  it  is  successful,  and  how  to  administer  it  in  order  to  obtain 
the  best  results.  The  question  o^  treatment  may  be  divided  into 
several  divisions,  namely,  the  moral  treatment,  the  treatment  by 
restraint,  the  treatment  by  law,  the  treatment  by  diet,  etc.,  and 
the  treatment  by  drugs. 

"The  method  or  methods  of  treatment  pertaining  to  each  of 
these  divisions  are  essential  to  success.  We  are  not  only  dealing 
with  the  physical  body,  but  with  human  nature  in  all  its  various 
complications,  and  we  are  compelled  to  consider  our  patients  in 
relation  to  the  question  of  heredity,  of  environment,  of  social 
customs,  social  status,  of  climate,  and  even  race.  The  religious 
belief  of  the  patient  may  have  to  be  taken  into  account.  It  is 
evident  that  no  'rule  of  thumb'  will  serve  us  here. 

"A  very  broad  conception  of  the  whole  question  and  a  com- 
bination of  the  various  methods  are  necessary  if  we  wish  to  be 
successful  in  the  treatment  of  the  majority  of  our  patients.  I  am 
convinced  that  this  very  lack  of  combination  accounts  for  so 
many  recorded  failures.  Let  us  take  these  various  methods  of 
treatment  in  their  order,  and  study  their  effect  upon  the  different 
varieties  of  the  disease. 

"THE  TREATMENT  OF  ALCOHOLISM  BY  DRUGS. 
"Before  proceeding  to  detail  the  actual  method  of  treatment 
by  drugs,  I  would  like  to  say  a  few  words  about  the  history  of 
the  movement  in  this  country.  One  is  quite  accustomed  now  to 
hear  of  a  patient  going  away  for  six  weeks  and  returning  cured 
of  his  alcoholism;  but  that  is  of  very  recent  date.  One  did  not 
hear  of  it,  say,  ten  years  ago — or  at  least  very  seldom.  Ten  years 


474  Narcotic  Drug  Diseases  and  Allied  Ailments. 

ago  any  advocate  of  the  short  term  of  drug  treatment  for  alcohol- 
ism was  more  often  laughed  at  than  listened  to. 

"When  I  founded  the  Norwood  Sanatorium  my  greatest  diffi- 
culty was  in  persuading  the  profession  that  there  was  anything  in 
the  treatment  of  alcoholism  by  means  of  drugs.  One  easily 
remembers  the  incredulous  smile  with  which  one's  statements 
were  received.  One  reads  of  our  insular  prejudice,  but  to  realise 
it  it  is  necessary  that  one  should  be  a  social  reformer  in  some 
direction ;  then,  and  only  then,  can  one  get  the  faintest  idea  of  its 
vastness  and  its  stolid  stupidity. 

"I  no  longer  wonder  that  the  French  shrug  their  shoulders  at 
us  in  despair.  But,  like  every  other  truth,  this  treatment  had  to 
prevail  in  the  end.  When  I  opened  the  Norwood  Sanatorium 
patients  came  to  me  in  spite  of  the  doctors — not  on  account  of 
them.  Some  were  told  by  their  doctors  that  all  sorts  of  harm 
would  befall  them  if  they  took  the  treatment ;  not  one,  but  several, 
were  told  they  might  consider  themselves  lucky  if  they  returned 
alive.  Others  were  told  that  the  treatment  would  affect  their 
heart  in  various  ways.  Others,  that  their  mind  was  in  danger. 
In  the  denseness  of  their  ignorance  of  the  whole  question  a  certain 
section  of  the  profession  carried  their  opposition  to  an  extent  that 
was  actual  persecution.  Nevertheless,  patients  presented  them- 
selves for  treatment,  were  cured,  and  reported  themselves  to 
their  doctors  on  their  return  home.  Thus  was  the  truth  greatly 
manifested. 

"To  show  to  what  an  extent  a  prejudiced  person  may  some- 
times go  rather  than  relinquish  his  prejudice,  the  following  inci- 
dent will  serve.  A  patient  entered  the  sanatorium  with  a  history 
of  daily  drinking  to  excess  covering  a  period  of  several  years. 
His  failing  was  known  to  all  the  villagers,  as  he  might  be  seen 
any  day  reeling  about  the  streets.  He  informed  me  that  his 
doctor  had  done  all  he  could  to  prevent  him  coming,  and  prophe- 
sied that  he  would  return  in  his  coffin. 

"When  he  returned  home  not  only  alive,  but  sober,  this 
doctor  made  a  bet  that  he  would  be  drinking  again  inside  of  a 


Craving  for  Alcohol  Abolished.  475 

week;  losing  this  bet  he  made  another — that  the  patient  would 
be  drinking  within  a  month;  when  he  lost  this  also  he  made  a 
still  further  one — that  he  would  relapse  inside  three  months.  On 
losing  this  bet,  in  order  to  prove  that  his  opinion  was  correct,  he 
resorted  to  a  trick  of  such  a  dastardly  nature  that  without  the 
fullest  proof  I  could  not  credit  it  of  any  member  of  our  profes- 
sion. Noticing  that  his  former  patient  had  a  slight  cough,  he 
called  him  into  his  surgery  and  made  him  up  a  cough  mixture — 
or  at  least  a  mixture  purporting  to  be  one. 

"This  mixture  contained  principally  alcohol  disguised.  On 
the  patient  attempting  to  take  it  he  vomited  freely,  telling  his 
wife  that  there  must  be  something  wrong  about  it.  But  his  wife 
told  him  that  some  cough  mixtures  were  intended  to  make  one 
sick — so  he  took  it  again,  with  a  similar  result.  On  asking  the 
doctor  for  an  explanation,  the  doctor  only  laughed,  but  admitted 
later  on  what  he  had  done.  Here  is  a  case  of  a  man  engaged  in 
one  of  the  noblest  professions  risking  this  man's  whole  career 
rather  than  give  up  his  prejudice.  Although  this  happened 
fifteen  years  ago,  I  am  glad  to  be  able  to  say  that  the  patient  has 
never  relapsed  and  has  held  an  important  position  all  that  time. 
Could  prejudice  go  further  than  this?  I  think  not.  Truth 
generally  triumphs  in  the  end,  and  now  we  find  the  treatment 
which  was  laughed  at  a  few  years  ago  given  the  foremost  place." 


CHAPTER  XXV. 

DELIRIUM  TREMENS. 

THIS  condition  may  be  defined  as  a  functional  dis- 
turbance coming  on  during  the  course  of  chronic  alco- 
holism. The  structural  lesions  are  the  same  as  in  chronic 
alcoholism  without  delirium,  but  the  structural  lesions 
are  not  the  cause  of  the  delirium  or  of  the  other  nervous 
manifestations  peculiar  to  this  condition. 

The  delirium  is  a  direct  product  of  a  toxin  in  the 
blood.  This  poison  doubtless  consists  in  part  of  alcohol 
itself  and  of  the  oxidized  products  of  alcohol,  and  in  part 
of  the  products  of  tissue  disintegration  and  their  fermen- 
tative compounds.  It  is,  therefore,  a  mixed  toxemia,  a 
drug,  intestinal,  and  auto-  toxemia.  The  severity  of 
the  attack — other  things  being  equal — depends  upon  the 
degree  of  concentration  or  potency  of  these  poisons. 

An  attack  may  be  precipitated  either  by  an  unusual 
excess  in  the  consumption  of  alcohol  in  a  habitual  user 
of  it  or  by  its  sudden  withdrawal;  also  by  shock  or 
traumatism. 

The  treatment  usually  advised  is  the  immediate  with- 
drawal of  alcohol  and  the  administration  of  sedative 
drugs  to  procure  sleep.  Tyson,  "Practice,"  ed.  1909, 
says:  "The  first  indication  after  the  withdrawal  of 
alcohol  is  to  procure  sleep."  For  this  purpose  full  doses 
of  sedative  drugs  are  recommended.  Anders's  "Prac- 
tice," last  edition,  advises  the  entire  withdrawal  of 
alcohol  and  the  administration  of  morphine  and  hyoscine 
to  procure  sleep. 

Nine  writers  out  of  ten  agree  with  the  recommenda- 
tions above  quoted.  All  advise  the  administration  of 
(476) 


High  Mortality  Under  Usual  Treatment.  477 

purgatives,  but  these  are  given  a  secondary  place.  The 
first  and  principal  endeavor  is  to  quiet  the  patient  and 
secure  sleep  by  the  administration  of  large  doses  of 
narcotic  and  sedative  drugs.  When  sleep  is  secured 
in  this  manner,  in  many  instances,  far  too  many,  the 
patient  goes  to  sleep  only  to  lapse  into  that  long  sleep 
which  knows  no  waking. 

This  statement  can  be  supported  by  almost  unlimited 
evidence,  but  to  quote  the  results  of  500  cases  of  delirium 
tremens  treated  at  the  Cook  County  Hospital,  Chicago, 
for  the  period  June,  1905,  to  August,  1908,  as  reported 
by  Ransom,  Journal  American  Medical  Association, 
April  17,  1909,  will  suffice.  In  this  series  about  one- 
third  were  delirious  when  admitted;  the  remainder 
developed  delirium  after  admission.  The  average  death 
rate  of  the  entire  500  cases  was  26.4  per  cent.,  but  in 
261  of  these  cases  sedative  drugs  were  given,  and  in  these 
the  mortality  ran  up  to  41.7  per  cent.  Bromides,  chloral, 
morphine,  and  scopolamine  were  the  sedatives  given. 

In  55  out  of  the  series  of  261  only  small  quantities  of 
these  sedatives  were  given,  and  in  this  series  the  death 
rate  was  21.8  per  cent.,  but  as  the  quantity  of  sedatives 
given  increased,  the  death  rate  increased.  In  the  72 
cases  receiving  the  largest  quantity  of  sedatives — esti- 
mated to  be  equivalent  to  180  to  240  grains  of  chloral 
in  each  twenty-four  hours — the  death  rate  was  65  per 
cent. 

A  mortality  such  as  the  above  in  the  treatment  of 
any  disease  certainly  calls  loudly  for  a  re-examination  of 
the  foundations  upon  which  our  plan  of  treatment  rests. 
The  author  has  felt  the  necessity  for  a  re-study  of  this 
subject  for  a  number  of  years,  and  has  devoted  con- 
siderable time  to  it.  The  object  of  this  paper  is  to  record 
the  results  of  that  effort.  The  plan  of  treatment  herein 


478  Narcotic  Drug  Diseases  and  Allied  Ailments. 

outlined  is  presented  as  the  result  of  his  own  clinical 
experience. 

The  indications  in  the  treatment  are : — 

Support  of  the  vital  functions. 

Control  or  arrest  of  delirium. 

Removal  of  poison  from  the  patient's  blood. 

In  attempting  to  carry  out  these  indications,  the 
condition  of  the  patient  in  all  particulars  must  be  care- 
fully estimated.  It  will  usually  be  found  that  the  stom- 
ach is  much  deranged;  that  the  fluids  taken  have  either 
been  vomited  or  have  been  but  sparingly  absorbed. 

Profuse  perspiration  is  another  symptom.  This  ex- 
cessive leakage  of  the  watery  element  of  the  blood  from 
the  pores  of  the  skin,  with  the  diminished  intake  or 
absorption  of  fluids,  pathologically  reduces  the  volume 
of  the  circulating  medium.  In  well-developed  cases  the 
pulse  is  rapid  and  deficient  in  volume :  the  heart  is  work- 
ing itself  to  exhaustion  in  an  ineffectual  effort  to  keep 
up  the  circulation  with  an  insufficient  volume  of  blood. 

The  spleen  is  usually  acutely  enlarged  and  there  is  a 
general  venous  stasis  of  the  portal  system.  The  func- 
tional activity  of  the  digestive,  secreting,  and  excreting 
organs  is  greatly  diminished,  if  not  entirely  suspended. 
In  many  cases  the  mental  excitement  is  so  great  as  to 
attract  and  practically  monopolize  the  entire  supply  of 
nerve  energy,  thereby  depriving  the  eliminating  organs 
of  excitor  impulses  to  such  an  extent  as  to  render  them 
inactive.  Our  efforts  should  be  directed  to  the  restora- 
tion of  a  physiological  distribution  of  both  nerve  energy 
and  blood-supply,  as  well  as  the  elimination  or  dilution 
of  the  poison  upon  which  the  excitement  depends. 

For  the  purpose  of  treatment  these  cases  should  be 
divided  into  two  principal  classes:  the  hyperemic,  or 
sthenic  type,  and  the  anemic,  or  asthenic  type.  In  the 


Classification  of  Cases.  479 

first  an  essential  factor  in  the  production  of  the  delirium 
is  an  hyperemia  of  the  brain. 

In  this  class  all  drugs  which  increase  the  blood-supply 
to  the  brain  increase  the  delirium.  In  these  cases  such 
drugs  as  strychnine,  hyoscine,  and  morphine  are  not 
only  harmful,  but  they  are  deadly.  In  the  other  class 
there  is  anemia  of  the  brain,  and  the  very  drugs  which 
are  contraindicated  in  the  hyperemic  cases  are  the  ones 
which  give  the  best  results  in  this  class  of  cases ;  on  the 
contrary,  the  bromides  and  other  cerebral  sedatives  are 
hurtful. 

About  90  per  cent,  of  the  cases  coming  under  the 
author's  care  have  been  hyperemic  and  10  per  cent, 
anemic.  It  is  not  always  easy  to  classify  them,  but  when 
in  doubt  the  administration  of  a  few  doses  of  gelseminine 
will  usually  show  whether  they  are  anemic  or  hyperemic. 
If  the  case  is  of  the  anemic  type  the  delirium  will  be 
increased  by  the  effects  of  this  remedy,  but  if  it  is  of  the 
hyperemic  type  the  delirium  will  not  be  aggravated,  but 
will  usually  be  markedly  quieted.  This  test  will  furnish 
a  clew  to  the  proper  class  of  therapeutic  agents  to  be 
employed  in  combating  delirium,  but  the  administration 
of  medicines  alone  is  not  to  be  depended  upon.  The 
plan  of  treatment  which  the  author  has  devised  is  as 
much  surgical  as  medical. 

As  above  suggested,  the  volume  of  blood  in  the 
hyperemic  cases  is  less  than  normal.  This  decrease  oc- 
curred, to  a  large  extent,  because  of  the  excessive  leak- 
age of  the  watery  element  of  the  blood  through  the  pores 
of  the  skin,  but  the  fluid  thus  escaping  carried  out  with 
it  only  an  insignificant  quantity  of  the  total  accumulation 
of  toxic  matter. 

The  fact  that  the  skin  has  not  permitted  any  material 
quantity  of  these  poisons  to  escape  with  the  fluid  which 


480  Narcotic  Drug  Diseases  and  Allied  Ailments. 

formerly  held  them  in  solution  has  left  the  blood  a  far 
more  concentrated  and  toxic  solution. 

In  normal  salt  solution  we  have  a  remedy  with  which 
this  condition  can  be  successfully  combated.  As  a 
primary  step  in  the  treatment,  fill  the  colon  with  this 
solution,  and  repeat  the  same  as  often  as  it  is  absorbed, 
about  every  two  hours,  but  if  the  attack  is  severe  do  not 
depend  upon  the  colon  alone  as  a  route  by  which  to  intro- 
duce this  solution.  Supplement  it  by  hypodermoclysis, 
and  in  extreme  cases  by  intravenous  injection,  the  pur- 
pose being  to  force  fluids  into  the  body  until  the  entire 
arterial  and  venous  systems  are  filled  to  their  utmost 
capacity. 

The  condition  of  the  patient  usually  greatly  improves 
upon  the  successful  carrying  out  of  even  this  step  in  the 
treatment.  The  heart,  having  an  ample  volume  of  fluid 
to  handle,  acts  much  less  rapidly  and  propels  a  larger 
quantity  of  fluid  by  each  contraction,  as  indicated  by  a 
more  full,  soft,  and  less  rapid  pulse. 

The  addition  of  this  fluid  to  the  concentrated  solution 
of  poison  of  which  the  diminished  volume  of  blood  con- 
sisted materially  dilutes  and  renders  less  irritating  the 
poison  in  the  blood ;  it  also,  in  a  very  short  time,  brings 
about  free  action  of  the  kidneys  and  thus  one  of  the 
channels  of  elimination  is  opened  up.  As  a  rule,  even 
this  degree  of  dilution  of  the  poison  lessens  the  mental 
excitement  and  allows  a  more  normal  distribution  of 
nerve  energy  of  all  the  vital  organs. 

Elimination  of  the  poison  is  essential  to  a  cure,  and 
the  bowels  and  the  kidneys  are  the  organs  upon  which 
we  must  depend  for  that  work;  therefore,  at  the  begin- 
ning of  treatment,  begin  the  administration  of  calomel 
in  doses  of  3  to  5  grains  every  hour,  and  continue  until 
as  much  as  four  full  doses  have  been  retained.  This 


Normal  Salt  Solution  Valuable.  481 

calomel  will  not  act  as  a  purgative  while  the  mental 
excitement  continues  to  be  so  great,  but  it  will  be  in  the 
system  ready  to  act  when  the  condition  of  the  nervous 
system  has  been  so  quieted  as  to  permit  it. 

After  the  colon  has  been  used  for  the  purpose  of 
absorbing  saline  solution  for  a  few  hours,  it  should  then 
be  brought  into  use  as  an  eliminating  organ.  Full  doses 
of  Epsom  salt  or  other  saline  should  be  given  and  re- 
peated at  frequent  intervals  until  large  quantities  of 
liquid  stools  have  been  passed.  The  mental  excitement 
does  not  retard  the  action  of  the  saline  cathartics  as 
greatly  as  it  does  the  action  of  cathartics  of  other  classes. 
Their  action  is  quite  effective  in  this  condition,  as  the 
watery  discharges  they  induce  drain  out  of  the  blood 
a  large  quantity  of  the  poison  with  which  we  are  con- 
tending. 

After  beginning  the  administration  of  the  salts,  the 
colon  can  no  longer  be  used  as  a  route  by  which  saline 
solution  can  be  introduced  into  the  system;  therefore, 
one  or  both  of  the  other  methods  should  be  continued, 
supplemented  by  free  administration  of  water  by  the 
stomach,  when  that  can  be  done,  to  the  end  that  the 
system  may  be  kept  well  supplied  with  fluids  while  it  is 
necessary  to  drain  the  same  out  by  the  kidneys  and 
bowels. 

This  practically  amounts  to  washing  the  poisons  out 
of  the  blood  by  forcing  fluid  into  it  and  draining  it  out 
by  the  natural  channels.  The  quantity  of  poison  elim- 
inated by  the  skin  is  so  small  that  it  is  hardly  to  be 
taken  into  account.  Bouchard  has  shown  that  the  bile 
is  about  nine  times  as  toxic  as  the  urine,  and  that  the 
urine  is  about  fifty  times  as  toxic  as  the  fluids  excreted 
by  the  skin.  Doubtless  other  matter  excreted  by  the 
bowels  is  fully  as  toxic  as  the  bile. 


482          Narcotic  Drug  Diseases  and  Allied  Ailments. 
SUPPORT  OF  HEART  AND  STIMULATION  OF  KIDNEYS. 

The  free  administration  of  the  normal  salt  solution 
so  improves  the  heart  action  that  it  is  often  unnecessary 
to  administer  other  agents  for  that  purpose;  still,  as  a 
further  precaution,  it  is  well  to  administer  sparteine 
sulphate  from  the  beginning  of  treatment  until  the 
patient  is  well  on  the.  road  to  convalescence.  This  is 
done  for  a  double  purpose.  Sparteine  is  not  only  our 
most  reliable  heart  tonic,  but  a  good,  non-irritating 
diuretic.  It  increases  the  force  and  lessens  the  frequency 
of  the  heart's  action,  dilates  the  smaller  arteries,  espe- 
cially the  arterial  capillaries,  and  aids  greatly  in  restor- 
ing circulatory  equilibrium.  Its  action  seems  to  be  con- 
fined to  the  cardiac  centers.  It  does  not  stimulate  the 
central  nervous  system,  as  do  strychnine  and  other 
remedies  of  that  class,  and  does  not  increase  the  delirium. 

Its  action  as  a  diuretic  is  not  well  understood,  but  it 
is  probably  due  to  its  power  to  improve  the  capillary 
circulation  in  the  kidney.  It  should  be  given  hypoder- 
mically  in  doses  of  2  grains  at  intervals  of  from  two  to 
six  hours.  Fractional-grain  doses  of  this  remedy  are 
entirely  insufficient.  It  should  be  given  in  both  the 
hyperemic  and  the  anemic  type  of  cases.  It  aids  materi- 
ally in  meeting  two  of  the  indications  in  the  treatment 
of  this  condition,  that  of  supporting  the  heart  and  pro- 
moting elimination  by  the  kidneys.  It  is,  therefore,  a 
remedy  of  the  greatest  value. 

CONTROL  OF  DELIRIUM  IN  THE  HYPEREMIC  CASES. 

The  active  and  often  violent  delirium  is  a  most 
troublesome  and  dangerous  symptom.  The  mental  ex- 
citement accompanying  it  not  only  throttles  the  activity 
of  the  eliminating  organs,  but  under  it  the  patient  ex- 


Hyperemic  Cases,  Delirium  in.  483 

hausts  himself  in  struggling  with  or  hiding  from  imagi- 
nary enemies;  therefore,  the  control  of  this  symptom  is 
of  first  importance,  but  it  must  be  done  by  agents  which 
promote  rather  than  hinder  the  action  of  purgatives, 
diuretics,  and  other  more  strictly  curative  agents. 

In  the  hyperemic  cases  gelseminine  is  the  remedy 
par  excellence  for  this  purpose.  It  should  be  borne  in 
mind  that  the  medical  plant  gelsemium  yields  two  alka- 
loids, gelseminine  and  gelsemine.  It  is  unfortunate  that 
these  alkaloids  have  been  given  so  nearly  the  same  name, 
as  their  action  is  not  at  all  similar.  Gelsemine  is  a 
stimulant  and  motor  excitant,  resembling  strychnine, 
while  gelseminine  is  a  motor  depressant  and  cerebral 
sedative.  It  is  to  the  latter  alkaloid  that  this  plant  owes 
its  medicinal  value. 

This  remedy  should  be  given  in  doses  of  %s  grain  at 
intervals  of  from  one  to  two  hours  in  the  hyperemic 
cases,  and  continued  until  its  full  physiological  effects 
are  established,  unless  the  delirium  and  other  excite- 
ment is  sooner  allayed.  It  lessens  the  blood-supply  to 
the  brain  and  thus  directly  combats  the  hyperemia,  upon 
which  the  delirium  largely  depends.  It  does  not  injuri- 
ously affect  the  heart  action  or  systemic  circulation,  and 
is  not  incompatible  with  sparteine.  The  effects  of  these 
two  remedies  can  be  established  in  the  system  at  one  and 
the  same  time. 

The  sedative  effects  of  gelseminine  on  the  cerebral 
centers  is  such  as  to  materially  reduce  the  delirium  in  the 
most  aggravated  cases,  and  in  the  milder  cases  it  often 
promptly  arrests  it.  Its  effects  in  reducing  cerebral  ex- 
citement permit  a  more  even  distribution  of  nerve 
energy,  and  this  brings  about  a  condition  in  which  the 
eliminating  organs  can  respond  to  the  purgatives  and 
other  curative  agents.  It  not  only  establishes  a  tempo- 


484  Narcotic  Drug  Diseases  and  Allied  Ailments. 

rary  quiet,  but  promotes  the  action  of  other  agents. 
Patients  often  sleep  from  its  effects. 

CONTROL   OF  DELIRIUM   IN   THE   ANEMIC   CASES. 

The  delirium  in  this  type  of  cases  differs  materially 
from  that  of  the  hyperemic  type,  especially  in  the  stage 
of  development.  In  the  hyperemic  cases  the  delirium 
develops  rapidly.  Usually  within  a  few  hours  or  a  day 
at  most,  the  delirium  is  active.  In  the  anemic  cases  the 
delirium  develops  slowly.  The  patient  will  see  a  snake, 
or  other  unpleasant  objects ;  the  shock  attending  this  acts 
as  a  stimulant  and  causes  the  heart  to  throw  a  more 
abundant  supply  of  blood  to  the  brain.  The  cerebral 
anemia  is  temporarily  overcome  and  the  mind  becomes 
clear. 

In  a  short  time,  as  the  effects  of  this  excitement  sub- 
side, the  blood-supply  to  the  brain  again  becomes 
deficient  and  another  hallucination  occurs,  followed  in 
turn  by  increased  activity  of  the  circulation  and  the  dis- 
appearance of  the  delusion.  This  phenomenon  occurs 
at  intervals  more  or  less  frequent,  sometimes  running 
one,  two,  or  several  days  before  the  patient  is  continu- 
ously delirious. 

In  this  class  of  patients  gelseminine  would  still 
further  lessen  the  blood-supply  to  the  brain  and  increase 
the  delirium.  Bromides  have  a  similar  effect.  It  is  in 
this  class  of  cases  that  hyoscine  and  strychnine  have 
proven  so  valuable,  but  strychnine  is  much  to  be  pre- 
ferred. It  is  a  general  systemic  and  cerebral  stimulant, 
and  by  increasing  the  blood-supply  of  the  brain  it  lessens 
or  suspends  delirium. 

Under  these  conditions  an  excitomotor  stimulant 
proves  to  be  a  sedative.  The  rest  and  repose  induced 
by  it  allow  or  promote  a  more  even  distribution  of  blood- 


Anemic  Cases,  Delirium  in.  485 

supply  and  nerve  energy  and  thus  bring  about  a  condi- 
tion in  which  the  eliminating  organs  will  respond  to 
stimulation.  Not  only  that,  but  strychnine  stimulates 
the  motor  functions  of  the  bowels  and  thus  directly  pro- 
motes the  action  of  cathartics,  the  principal  curative 
agents. 

BLOOD-PRESSURE  IN  THE  ASTHENIC  TYPE  OF  CASES. 

It  is  extremely  difficult  to  get  accurate  blood-pressure 
records  and  the  pulse  tracing  in  delirium  tremens  cases, 
especially  in  the  sthenic  type  of  cases,  because  of  the 
difficulty  in  keeping  the  patient  still  long  enough  to 
obtain  such  records,  but  in  the  asthenic,  or  anemic,  type 
this  difficulty  is  not  so  great.  In  the  asthenic  type  the 
author  has  been  able  to  get  accurate  records  in  a  number 
of  cases,  sufficient  to  afford  a  fair  index  to  the  condition 
of  arterial  tension  in  such  cases,  but  in  the  sthenic,  or 
hyperemic,  type  he  has  not  been  able  to  get  records  in 
such  numbers  as  to  justify  a  general  conclusion. 

The  one  striking  feature  in  the  anemic  type  of  cases 
has  been  the  uniformly  low  pulse-pressure,  the  abnor- 
mally small  difference  between  the  systolic  and  the 
diastolic  pressure.  So  long  as  this  abnormally  low  pulse- 
pressure  continued  the  delirium  continued,  but  as  the 
proper  relation  between  the  systolic  and  the  diastolic 
pressure  was  restored,  either  by  the  temporary  effects 
of  the  remedies  administered  or  by  general  improve- 
ment of  the  patient's  condition,  the  delirium  subsided. 

The  author  points  to  this  fact,  now  instrumentally 
verified,  in  support  of  his  contention,  announced  some 
years  ago,  that  the  condition  of  the  cerebral  circulation, 
as  indicated  by  a  low  or  high  arterial  tension,  is  an 
important  factor  in  the  causation  of  the  delirium;  and, 
that  it  also  furnishes  an  index  to  the  class  of  remedies 
to  be  used  in  its  control. 


486  Narcotic  Drug  Diseases  and  Allied  Ailments. 

In  the  sthenic  type  of  cases,  strychnine  and  other 
cerebral  stimulants  increase  the  delirium,  while  in  the 
asthenic  type  they  allay  it. 

The  blood-pressure  and  pulse  tracings  in  the  follow- 
ing case  are  typical  of  the  author's  series  of  anemic 
cases:  J.  T.  P.  Aged  35.  Weight,  160;  admitted  June 
17,  1912.  Had  been  in  stupor  with  intermitting,  mild 
delirium  for  several  days;  was  brought  from  his  home 
on  stretcher.  Had  not  been  able  to  get  him  to  take  either 
medicine  or  whisky  for  a  couple  of  days.  Physical 
examination  showed  conditions  usually  found  in  chronic 


Tracing  No.  i. 

alcoholics,  with  possibly  an  exaggerated  degree  of 
muscular  relaxation  and  with  more  than  usually  marked 
irregularity  of  respiration.  Pulse  rate  was  no;  blood- 
pressure,  systolic  112,  diastolic  95;  pulse-pressure,  17. 
Respiration  about  12  per  minute,  very  irregular.  Pulse 
tracing  No.  i  taken. 

Not  being  able  to  get  the  patient  to  swallow  anything, 
20  grains  calomel  were  put  in  mouth  and  rubbed  into 
mucous  membrane.  Strychnine,  %o  gram>  with  10 
minims  i :  1000  solution  adrenalin,  were  given  hypo- 
dermically,  and  this  was  followed  in  short  time  by  i 
quart  normal  salt  solution  by  hypodermoclysis  and  i 
quart  by  rectum. 

The  strychnine  and  adrenalin  made  so  little  impres- 
sion that  it  could  not  be  detected,  but  within  a  couple 
of  hours  after  the  administration  of  the  salt  solution  the 


Low  Pulse-pressure  in  Anemic  Cases.  487 

pulse  showed  considerable  increase  in  volume  and  the 
patient  was  not  so  stupid,  but  when  he  was  aroused  he 
was  delirious.  Four  hours  from  the  time  of  giving  the 
salt  solution,  the  kidneys  acted  freely. 

The  principles  of  treatment  heretofore  outlined  in 
this  chapter  for  anemic  cases  were  carried  out  in  this 
case,  with  the  addition  of  l/2  grain  of  cocaine  every  four 
hours  as  a  respiratory  stimulant,  but  it  required  four 
days  to  so  cleanse  the  system  of  the  toxic  matter  that 
material  improvement  in  his  condition  could  be  noticed. 
It  was  extremely  difficult  to  get  the  patient  to  swallow 
anything  and  this  prevented  the  free  use  of  saline  cathar- 
tics. Dry  calomel  by  the  mouth  and  strychnine  hypo- 
dermically  finally  stimulated  the  secretory  and  motor 
functions  to  such  a  degree  as  to  be  followed  by  free 
action  of  the  emunctories.  Saline  solution  and  sparteine 
kept  the  kidneys  acting,  and  each  day  the  patient  was 
brought  to  a  somewhat  safer  condition. 

On  the  fourth  day  from  beginning  of  treatment, 
after  the  bowels  had  acted  quite  freely,  the  blood-pres- 
sure record  was  as  follows:  systolic,  105;  diastolic,  80; 
pulse-pressure,  25;  pulse  rate,  100.  While  this  was  a 
decrease  in  both  systolic  and  diastolic  pressure,  the 
increase  in  the  pulse-pressure,  indicating  more  nearly 
normal  arterial  tension,  was  in  harmony  with  the  gener- 
ally improved  condition  of  the  patient  in  other  respects. 
The  deep  stupor  had  given  way  to  a  condition  of  lassi- 
tude from  which  the  patient  could  be  aroused  to  take 
nourishment,  etc.,  and  when  so  aroused  would  make 
intelligent  answers  to  questions  propounded  to  him.  So 
long  as  he  was  fully  awake  and  his  attention  attracted 
to  anything  his  mind  was  clear,  but  when  left  to  himself 
he  would  lapse  into  semisleep,  his  mind  would  wander, 
and  he  would  talk  to  imaginary  persons. 


488  Narcotic  Drug  Diseases  and  Allied  Ailments. 

From  this  condition  there  was  gradual  improvement, 
until  three  days  later  the  stupor  had  entirely  disappeared 
and  his  mind  was  clear  at  all  times.  At  this  time  the 
following  record  was  taken:  pulse  rate,  90;  respiration, 
16;  blood-pressure,  systolic  125,  diastolic  95;  pulse- 
pressure,  30.  Pulse  tracing  No.  2,  made  at  this  time, 
shows  the  character  and  volume  of  the  pulse. 

The  record  in  this  case  is  in  entire  accord  with  the 
author's  experience  in  treating  patients  of  this  type. 
When  the  blood-pressure  instrument  showed  a  marked 
divergence  from  the  normal  relation  between  the  systolic 


Tracing  No.  2. 

and  diastolic  pressure,  and  this  divergence  indicated 
abnormally  low  arterial  tension,  the  delirium  developed 
more  gradually;  was  of  less  violent  type,  usually  inter- 
mitting in  character;  ran  a  more  chronic  course,  and 
was  at  least  temporarily  relieved  by  the  action  of  reme- 
dies such  as  strychnine  and  adrenalin,  which  increase 
arterial  tension,  and  the  delirium  disappeared  entirely 
when  the  normal  arterial  tension  was  restored  and  main- 
tained. 

While  the  delirium  is  only  a  symptom  of  the  main  dis- 
order, it  is  a  symptom  of  such  great  importance,  and  so 
influences  and  overshadows  other  conditions  present, 
that  the  entire  treatment  should  be  planned  with  refer- 
ence to  it,  especially  in  the  sthenic  type  of  cases,  since  if 
it  is  left  uncontrolled  the  patient  may  exhaust  himself 
before  the  curative  remedies  can  be  made  to  act. 


Pulse-pressure  Restored.  489 

Most  writers  advise  the  abrupt  and  complete  with- 
drawal of  alcohol  as  soon  as  the  patient  is  taken  in  hand, 
but  with  that  the  author  cannot  agree.  In  his  experience 
there  is  no  more  certain  way  to  precipitate  or  aggravate 
an  attack  of  delirium  tremens  than  to  stop  the  alcohol  at 
once.  It  is  true  that  alcohol  is  one  of  the  poisons  which 
is  causing  the  delirium,  but  it  is  not  the  principal  one. 

On  the  other  hand,  alcohol  is  an  anesthetic,  a 
paralyzer  of  motion  and  sensation.  Its  primary  effect, 
lasting  for  several  hours  at  least,  does  much  more  to 
blunt  the  sensibilities  of  the  cerebral  centers  and  lessen 
the  delirium  than  it  does  to  excite  it,  and  does  this  with 
much  less  interference  with  the  action  of  curative  reme- 
dies than  do  any  of  the  narcotic  drugs  so  often  employed. 

A  full  drink  of  whisky  will  often  allay  an  incipient 
delirium  for  several  hours  and  thus  give  a  more  favor- 
able opportunity  for  the  action  of  other  remedies. 

The  author  now  never  completely  withdraws  alcohol 
as  long  as  the  patient  has  or  is  threatened  with  delirium, 
but  merely  reduces  its  consumption  to  a  moderate  quan- 
tity, y%  or  I  pint  in  twenty-four  hours  being  allowed  to 
those  who  had  been  consuming  from  I  to  2  quarts  in  the 
same  length  of  time.  After  all  symptoms  of  delirium 
have  subsided,  alcohol  is  withdrawn,  but  not  suddenly. 

Patients  treated  after  this  plan  rarely  require 
hypnotics.  They  usually  sleep  naturally  as  soon  as 
elimination  has  progressed  to  such  an  extent  as  to  allay 
the  delirium,  but,  if  hypnotics  are  needed,  then  moderate 
doses  of  chloral  or  veronal  may  be  used.  Apomorphine 
in  doses  of  Vso  to  ^o  grain  is  a  valuable  and  safe  hyp- 
notic in  this  class  of  patients. 

Large  doses  of  the  sleep-producing  and  sedative 
drugs  should  not  be  given.  It  is  far  better  to  allow  the 
patient  to  remain  awake  than  to  take  the  risk  of  fore- 


490  Narcotic  Drug  Diseases  and  Allied  Ailments. 

ing  sleep  upon  him  with  large  narcotic  doses.  In  the 
author's  opinion  there  is  no  place  in  the  treatment  of 
this  disorder  for  the  use  of  opiates  in  any  form.  The 
sedative  and  hypnotic  effect  of  a  neutral  bath  is  far 
preferable  to  effects  of  narcotics. 

RESULTS  THUS  FAR  OBTAINED. 

The  author's  work  for  the  past  twelve  years  has  been 
limited  to  the  treatment  of  alcohol  and  drug  diseases. 
For  the  first  five  years  of  that  time  the  delirium  tremens 
cases  were  treated  according  to  plans  advised  by  the 
leading  authors,  but  with  a  mortality  far  too  great  to  be 
satisfactory.  This  led  to  an  independent  study  of  the 
question,  and  in  the  course  of  six  months  the  author  had 
practically  formulated  the  plan  of  treatment  herein 
outlined. 

During  the  seven  years  since  this  plan  has  been 
adopted,  we  have  admitted  an  average  of  100  alcohol 
cases  annually.  Quite  a  number  of  those  had  delirium 
when  admitted  and  others  developed  it  after  admission, 
but  out  of  the  entire  series  of  700  cases  we  have  only 
had  the  misfortune  to  lose  i  patient  from  delirium 
tremens. 

This  is  such  a  pleasing  contrast  with  our  former 
experience  that  the  author  thinks  he  should  be  excused 
if  he  seems  somewhat  enthusiastic  in  the  advocacy  of 
his  present  method.  Not  only  has  the  mortality  been 
reduced  to  almost  zero,  so  far  as  this  series  of  cases  are 
concerned,  but  the  number  developing  delirium  in  the 
institution  has  been  reduced  to  a  very  low  point.  We 
rarely  admit  an  alcoholic  who  is  on  a  temporary  spree, 
but  our  cases  consist  of  the  most  chronic  type,  those  who 
have  gone  to  the  limit  and  are  therefore  forced  to  seek 
help. 


Mortality  Should  be  Low.  491 

Every  one  of  those  would  be  subject  to  delirium 
during  the  sobering-up  period,  and  under  the  plan  ordi- 
narily pursued  from  20  to  25  per  cent,  of  them  would 
almost  certainly  have  developed  delirium  at  some  stage 
of  treatment.  In  this  series  the  number  that  developed 
delirium,  even  to  the  mildest  degree,  did  not  exceed  5  per 
cent.,  and  in  these,  as  a  rule,  that  symptom  was  overcome 
within  the  first  twelve  hours  of  the  treatment,  and  often 
in  half  that  time.  In  none  of  the  cases  admitted  with 
delirium  has  that  symptom  resisted  the  treatment  longer 
than  twenty-four  hours  and  rarely  longer  than  twelve 
hours. 

In  connection  with  the  administration  of  the  saline 
solution,  gelseminine  in  the  hyperemic  cases  allays  the 
delirium  by  the  time  the  full  effects  of  that  remedy  are 
developed,  if  not  earlier,  and  in  the  anemic  cases  strych- 
nine or  hyoscine  does  so.  During  the  respite  thus  ob- 
tained the  flushing  and  eliminating  process  above 
outlined  is  pushed  and  after  that  the  delirium  does  not 
recur. 

In  the  early  part  of  this  series  of  cases  veratrum  was 
used  instead  of  gelseminine  as  a  cerebral  sedative  and 
motor  depressant,  but  with  more  experience  the  author 
finds  that  gelseminine  is  much  to  be  preferred. 

In  the  sthenic  type  of  cases,  when  the  delirium  is 
active  and  the  patient  is  hard  to  control,  a  large  dose  of 
veratrum,  10  to  20  minims  of  Norwood's  tincture,  or 
%o  grain  apomorphine  will  often  relax,  nauseate,  and 
quiet  the  patient  and  not  only  do  much  to  remove  the 
necessity  for  physical  restraint,  but  will  bring  about  a 
condition  favorable  for  the  administration  of  other 
remedies  and  allow  time  for  their  curative  effects  to 
become  established. 

In  the  asthenic  or  anemic  type  of  cases  strychnine 
or  hyoscine  serves  the  same  purpose. 


492  Narcotic  Drug  Diseases  and  Allied  Ailments. 

So  fully  is  the  author  convinced  of  the  soundness  of 
the  principles  upon  which  this  plan  of  treatment  is  based 
that,  in  an  extreme  case,  he  would  not  hesitate  to  open  a 
vein  and  allow  the  patient  to  bleed  until  he  fainted,  and 
then  at  once  replace  the  blood  lost  by  intravenous  injec- 
tion of  two  or  three  times  its  volume  of  normal  salt  solu- 
tion. It  is  believed  this  would  be  an  ideal  step  in  the 
management  of  a  case  of  that  class,  but  thus  far  the 
author  has  not  found  it  necessary  to  go  to  that  extent, 
the  less  radical  measures  having  been  sufficient. 

Physical  restraint  is  mentioned  only  to  be  condemned. 
It  should  be  used  only  to  the  extent  which  may  be  neces- 
sary to  permit  the  administration  of  the  saline  solution. 

To  RECAPITULATE. 

•  It  is  contended  that  this  condition  is  a  mixed  toxemia, 
a  drug,  intestinal,  and  an  auto-  toxemia,  and  that  the 
virulence  and  activity  of  the  poisons  in  the  blood  are 
increased  by  the  progressive  loss  of  fluids,  with  a  dimin- 
ished intake  of  same. 

That  the  difficult  and  labored  heart  action  is  largely 
due  to  the  decreased  volume  of  circulating  medium. 
That  a  leading  factor  in  the  immediate  causation  of  the 
delirium  is  an  hyperemia  of  the  brain  in  a  large  majority 
of  the  cases  and  an  anemia  of  the  brain  in  a  small  per 
cent,  of  them.  In  the  treatment  it  is  essential  to  differen- 
tiate these  in  order  to  intelligently  apply  remedies  to 
control  delirium. 

The  first  indication,  that  of  support  of  the  vital  func- 
tions, so  far  as  the  heart  is  concerned,  is  most  effectively 
provided  for  by  the  administration  of  normal  salt  solu- 
tion and  by  sparteine.  These  agents,  at  the  same  time, 
are  the  most  effective  means  of  promoting  free  action 
of  the  kidneys.  They  also  contribute  in  no  small  degree 


The  Pathology — a  Mixed  Toxemia.  493 

to  meeting  the  second  and  third  indications,  that  of 
control  of  delirium  and  elimination  of  the  poison  from 
the  blood. 

In  the  hyperemic  cases  gelseminine,  and  in  the 
anemic  cases  strychnine,  by  regulating  the  supply  of  the 
blood  to  the  brain,  at  least  temporarily  restores  a  tranquil 
condition,  in  which  the  eliminating  organs  can  be  made 
to  respond  to  purgatives  and  diuretics,  which  are  the 
principal  curative  agents. 


CHAPTER  XXVI. 

TREATMENT  OF  ACUTE  AILMENTS  OCCURRING 
IN  ALCOHOLIC  SUBJECTS. 

IN  the  treatment  of  any  acute  ailment  it  is  well  to 
ascertain  whether  or  not  that  ailment  has  occurred  in 
one  who  is  otherwise  well  and  sound,  or  whether  it  has 
occurred  in  one  who  is  suffering  from  some  other  ail- 
ment, either  acute  or  chronic. 

Any  ailment  occurring  in  a  person  who  is  suffering 
from  some  pre-existing  disease  is  materially  influenced 
by  such  disease,  and,  in  turn,  the  pre-existing  disease 
may  be,  and  often  is,  materially  aggravated  by  the  oc- 
currence of  the  acute  ailment. 

Chronic  alcoholism  has  not  been  generally  recognized 
as  a  disease  in  the  sense  that  that  word  is  ordinarily 
used,  but  the  time  has  come  when  the  profession  is  ready 
to  so  classify  it.  Its  existence  in  any  person  certainly 
intensifies  any  acute  ailment  with  which  that  person 
may  be  attacked.  Every  acute  ailment  occurring  in  an 
alcoholic  subject  must  be  considered  as  being  gravely 
complicated  by  the  coexistence  of  the  alcoholic  condition. 
If  the  acute  ailment  be  of  an  inflammatory  type,  it  is 
intensified  to  a  greater  degree  than  if  it  is  non-inflam- 
matory, and  the  prognosis  is  rendered  correspondingly 
more  grave. 

There  are  several  types  of  chronic  alcoholism,  and 
these  types  affect  any  intercurrent  disease  differently; 
that  is  to  say,  such  acute  intercurrent  disease  is  likely  to 
show  complications  differing  in  type,  that  difference 
depending  on  the  type  of  alcoholic  subjects  in  which  it 
occurs. 

(494) 


Alcohol  a  Depressant.  495 

In  beer  and  wine  drinkers  heart  complications  are 
more  likely  to  occur  than  in  those  who  drink  stronger 
forms  of  alcoholic  beverages.  It  has  been  shown  by 
Krehl  and  others  that  beer  drinkers  develop  hypertrophy 
of  the  heart  to  a  much  greater  degree  than  do  the 
drinkers  of  stronger  forms  of  alcoholic  liquors.  The 
next  in  frequency  to  show  such  hypertrophy  are  the  wine 
drinkers. 

Any  acute  ailment  puts  an  additional  amount  of  work 
on  the  heart,  and  this  is  likely  to  break  the  compensation, 
which  usually  exists,  in  the  hypertrophied  heart  of  beer 
or  wine  drinkers,  and  this  break  in  compensation  often 
proves  to  be  the  complication  which  terminates  the 
patient's  life. 

In  those  who  drink  the  stronger  forms  of  alcoholic 
liquors,  there  is  more  likely  to  be  an  acutely  dilated  heart, 
accompanied  by  extreme  weakness.  This  is  often  more 
marked  in  periodic  drinkers  than  in  regular  drinkers. 
True  hypertrophy  of  the  heart  does  not  often  exist  in 
this  type  of  alcoholics,  but  there  is  frequently  almost 
complete  exhaustion  of  heart  power ;  in  fact,  in  all  forms 
of  chronic  alcoholism,  the  power  of  the  heart  and  the 
reserve  forces  on  which  its  action  depends  are  extremely 
low ;  therefore,  this  organ  must  not  only  be  watched,  but 
supported,  uniformly  supported,  from  the  very  begin- 
ning of  any  acute  ailment  occurring  in  a  chronic  alcoholic 
subject. 

It  has  been  taught  from  the  earliest  dawn  of  history 
that  alcohol  is  a  stimulant,  but  it  is  now  known  that  it 
is  not  a  stimulant  in  any  stage  of  its  action.  Neither  is 
it  a  food,  but,  on  the  other  hand,  it  is  a  protoplasmic 
poison,  a  depressant,  an  anesthetic,  an  anodyne,  a  nar- 
cotic, a  paralyzer  of  sensation,  motion,  and  intellect.  It 
is  not  appropriated  by  the  system  to  the  repair  of  waste, 


4%  Narcotic  Drug  Diseases  and  Allied  Ailments. 

or  to  the  building  up  of  tissue,  but  is  oxidized  to  render 
it  less  poisonous  and  to  prepare  it  for  excretion. 

Alcohol  depresses  the  inhibitory  centers  governing 
heart  action,  thus  allowing  the  excitomotor  function  to 
be  carried  on  without  the  inhibiting  and  regulating  con- 
trol of  these  centers.  Because  of  this  decreased  inhibi- 
tion, the  heart  acts  extravagantly  and  expends  what 
reserve  energy  there  may  be;  therefore,  when  called 
upon  to  do  any  extra  work  it  is  totally  unprepared  to 
meet  the  emergency. 

At  the  beginning  of  treatment  of  any  acute  ailment 
it  is  well  to  ascertain,  as  definitely  as  possible,  the  condi- 
tion of  every  vital  organ  and  to  estimate,  as  accurately 
as  may  be,  the  chances  of  that  organ  holding  out  to  do 
its  work  during  the  time  such  acute  ailment  is  expected 
to  exist. 

If  the  vital  organs  are  found  to  be  in  good  order  and 
in  condition  to  work  as  normal  organs,  then  the  prog- 
nosis is  more  favorable,  but  where  such  organs  are  found 
to  be  structurally  diseased,  or  materially  impaired  by 
overfunctional  activity,  the  chances  for  recovery  are 
very  much  reduced. 

In  the  chronic  alcoholic  the  heart  may  be  compared 
to  an  animal.  One  who  starts  on  a  journey  on  a  fresh, 
stout  horse  can  calculate  with  reasonable  certainty  to 
make  that  journey  safely  and  on  time,  but  if  he  starts  out 
on  a  horse  that  is  already  jaded,  one  which  has  already 
exhausted  his  reserve  strength,  he  will  not  likely  succeed 
in  making  the  journey  safely,  if  at  all,  and  certainly  not 
on  time. 

In  the  chronic  alcoholic  the  heart  is  in  the  same  con- 
dition as  the  jaded  horse :  it  has  already  been  on  a  long 
journey,  has  been  overworked,  and  is,  therefore,  not  in 
a  condition  to  do  normal  work,  much  less  to  do  the  extra 


Alcohol  Retards  Elimination.  497 

work  incident  to  an  acute  ailment.  Therefore,  if  this 
journey  is  to  be  made  with  safety,  every  particle  of  work 
which  can  be  taken  off  this  jaded  heart  must  be  taken 
off,  and  even  then  we  may  not  be  able  to  give  it  enough 
relief  to  enable  it  to  go  to  the  end  in  safety. 

All  forms  of  alcoholic  drinks  interfere  with  and 
decrease  the  elimination  of  waste,  and  also  are  toxic 
per  se;  therefore,  the  system  of  every  person  using 
alcohol  to  any  extent  whatever  is  in  a  toxic  condition. 
The  degree  of  this  toxic  state  depends  upon  the  extent 
and  length  of  time  during  which  the  alcoholic  drinks 
have  been  employed. 

The  presence  of  this  toxic  matter  interferes  with  the 
functional  activity  of  every  organ  in  the  body,  and  the 
existence  of  these  toxins  in  the  blood  greatly  aggravates 
any  intercurrent  disease,  especially  of  an  inflammatory 
type.  In  fact,  it  imparts  to  the  inflammatory  condition 
an  erysipelatous  nature,  a  disposition  to  spread  with 
great  rapidity  and  to  increase  in  severity  to  the  most 
intense  type. 

This  disposition  to  increase  rapidly  and  spread  ex- 
tensively continues  so  long  as  this  toxic  state  is  allowed 
to  continue;  therefore,  an  alcoholic  subject  attacked  by 
any  inflammatory  disease  is  likely  to  reach  a  dangerous 
point  in  a  very  short  time,  and  the  mortality  is  extremely 
high.  This  is  true  in  traumatic  as  well  as  other  forms 
of  inflammatory  disease. 

In  order  to  successfully  treat  any  acute  ailment  oc- 
curring in  an  alcoholic  subject,  the  toxic  condition  inci- 
dent to  the  use  of  alcohol  must  be  vigorously  treated  and 
overcome;  otherwise,  the  acute  disease  will  be  much 
aggravated  if  not  rendered  fatal. 

In  such  conditions  one  cannot  wait  for  the  restorative 
forces  of  nature  to  overcome  the  acute  ailment.  The 

82 


498  Narcotic  Drug  Diseases  and  Allied  Ailments. 

expectant  plan  of  treatment  simply  means  to  sit  by  and 
allow  the  patient  to  be  killed  by  the  two  ailments  co- 
existing, whereas,  had  the  system  been  in  normal  condi- 
tion, and  only  attacked  by  a  single  acute  ailment,  the 
restorative  forces  of  nature  might  have  been  suffi- 
cient to  carry  the  issue  to  a  favorable  termination.  The 
physician  who  would  successfully  treat  any  acute  ailment 
in  a  chronic  alcoholic  subject  must  act  promptly  and 
vigorously,  to  the  end  that  the  patient's  system  be  free 
from  toxic  matter  incident  to  the  alcoholic  condition,  and 
thereby  be  given  a  chance  to  rally  its  forces  to  combat 
the  acute  ailment. 

The  stomach  is  another  organ  which  is  always  ma- 
terially impaired  in  alcoholic  subjects,  and  this  impair- 
ment differs  somewhat  in  beer  drinkers  from  that 
which  is  found  in  those  who  use  a  more  concentrated 
form  of  alcoholic  beverage.  Beer  drinkers  consume 
large  quantities  of  fluid,  and  usually  eat  frequently  and 
inordinately,  and  this  results  in  an  overdistention  of  the 
stomach. 

This  type  of  alcoholic  patients  usually  have  chronic 
dilatation  of  the  stomach,  with  descent  of  that  organ  to 
a  greater  or  less  degree.  There  also  exists  the  catarrhal 
conditions  which  are  common  to  all  chronic  alcoholics, 
but  the  catarrhal  condition  is  usually  more  marked  in 
alcoholic  subjects  who  use  the  more  concentrated  forms 
of  alcoholic  drinks.  There  is  also  a  more  intense  degree 
of  catarrh  in  those  who  drink  regularly  than  there  is  in 
those  who  drink  periodically. 

The  existence  of  the  conditions  above  outlined 
renders  the  prognosis  of  any  acute  ailment  occurring  in 
an  alcoholic  subject  much  more  grave  than  the  same 
ailment  occurring  in  one  not  an  alcoholic  subject.  These, 
however,  are  truisms  generally  known  and  accepted  by 


Catarrh  of  Stomach  Important.  499 

all  physicians,  but  the  burning  question  is:  What  can 
be  done  to  overcome  these  complications  and  bring  the 
patients  to  a  successful  convalescence?  Can  this  toxic 
condition  of  the  system  be  so  overcome  during  the  acute 
ailment  as  to  neutralize  and  negate  its  effect  on  the 
course  of  the  acute  ailment  ? 

This  can  usually  be  done,  but,  in  order  to  do  it,  the 
patient  must  be  intelligently  and  vigorously  treated  for 
his  alcoholic  toxemia  as  well  as  for  the  acute  ailment.  If 
one  ignores  the  existence  of  so  important  a  complication 
as  the  toxic  condition  incident  to  the  use  of  alcohol  and 
merely  treats  the  acute  ailment  as  he  would  such  an 
ailment  in  one  not  an  alcoholic  subject,  he  is  simply 
riding  for  a  fall  and  his  patient  will  almost  certainly  be 
carried  to  an  untimely  grave. 

The  principles  upon  which  the  alcoholic  toxic  state 
can  be  successfully  treated  are  sufficiently  outlined  in  the 
chapters  on  Alcoholism,  and  the  reader  is  referred  to 
them  for  the  details  of  such  treatment.  The  author 
simply  wishes  to  say  here  that  it  is  best  for  the  physician 
to  forget  the  fact,  if  possible,  that  the  patient  has  an 
acute  ailment,  and  to  look  at  the  condition  rather  than 
any  disease. 

Thorough,  conservative,  but  persistent  elimination, 
both  by  the  kidneys  and  bowels,  as  outlined  in  the 
chapter  on  the  Treatment  of  Alcoholism  should  be  ap- 
plied to  the  treatment  of  these  cases,  and  then  such  other 
suitable  remedies  as  are  indicated  to  meet  the  acute  ail- 
ment should  be  given.  In  other  words,  the  physician 
must  take  absolute  control  of  every  vital  function,  and 
not  only  see  that  the  eliminating  organs  act  promptly 
and  efficiently,  but,  in  addition,  he  must  control  and 
support  the  heart,  lungs,  and  every  other  function  upon 
which  animal  life  depends. 


500  Narcotic  Drug  Diseases  and  Allied  Ailments. 

The  work  of  the  heart  is  greatly  increased  by  the 
toxic  state  of  the  system,  and,  since  this  toxic  state 
uniformly  results  in  portal  congestion,  thorough  purga- 
tion induced  by  purgative  courses,  which  stimulate  all 
the  functions  concerned  in  the  evacuation  of  waste, 
proportionately  and  at  the  same  time,  is  the  first  and 
most  essential  step  in  overcoming  the  alcoholic  toxic 
state,  and  it  is  frequently  the  most  thoroughly  indicated 
and  most  important  step  in  the  treatment  of  the  acute 
ailment. 

The  author,  however,  would  impress,  upon  anyone 
attempting  to  treat  acute  ailments  in  a  patient  of  this 
type,  the  fact  that  a  saline  cathartic  cannot  be  depended 
upon  to  thoroughly  empty  the  intestinal  canal  and  disen- 
gorge  the  portal  system.  These  agents  merely  empty 
the  colon  and  leave  the  upper  digestive  tract  to  retain 
whatever  pent-up  matter  there  is  in  it.  He  would  also 
insist  upon  the  proposition  that  no  single  purgative 
course  is  sufficient  to  remove  the  obstruction  usually 
found  in  the  portal  system  of  such  cases.  Purgation 
must  be  continued,  day  after  day,  until  that  work  is 
thoroughly  done.  However,  this  should  be  done  by 
remedies  which  act  conservatively,  to  the  end  that  the 
patient's  strength  may  be  preserved  as  much  as  possible. 
The  author  has  found  the  following  purgative  course  to 
act  efficiently  in  such  cases : — 

T$>  Calomel, 

Extract  of  cascara   aa  gr.  x. 

Podophyllin, 

Ipecac    aa  gr.  j. 

Atropine  sulphate   gr.  %0- 

Strychnine  nitrate  gr.   %Q. 

Make  4  capsules.    Sig. :     One  every  two  hours  until  4  are 
taken. 


Purgative  for  Alcoholics.  501 

This,  as  all  other  purgatives,  should  be  given  on  an 
empty  stomach.  If  free  evacuation  of  the  bowels  does 
not  occur  within  eight  hours  from  the  time  the  last  of 
the  above  capsules  were  given,  a  full  dose  of  castor  oil  or 
a  saline  cathartic  should  be  given.  However,  this  should 
be  preceded  by  the  administration  of  ^o  grain  strych- 
nine. A  purgative  course  similar  to  the  above  should  be 
repeated  forty-eight  hours  from  the  time  the  first  course 
was  given,  and  then  such  additional  evacuants  should  be 
given  as  the  condition  seems  to  demand. 

Among  the  complications  which  are  to  be  expected 
is  delirium  tremens.  The  cleansing  of  the  system  of 
toxic  matter  reduces  the  danger  of  delirium,  but,  to 
further  guard  against  it,  the  alcoholic  drinks  should  be 
continued  for  a  time  during  the  acute  ailment.  It  must 
be  remembered  that  an  attack  of  delirium  tremens  is 
frequently  precipitated  by  the  suppression  of  the  use 
of  alcohol,  and,  as  the  occurrence  of  delirium  tremens 
during  the  course  of  any  acute  ailment  would  be  a  most 
serious  complication,  it  is  best  to  continue  the  use  of 
alcohol  until  the  danger  of  such  complications  has  passed. 

The  only  reason,  however,  for  continuing  the  alco- 
holic drinks  during  any  part  of  acute  ailment  is  for  its 
temporary  sedative  effects  and  for  the  purpose  of  avoid- 
ing delirium  tremens.  The  author  a  number  of  years 
ago  discarded  alcohol  from  his  armamentarium,  and  now 
never  uses  it  in  an  acute  ailment  in  one  not  an  alcoholic 
subject;  however,  when  an  acute  ailment  occurs  in  an 
alcoholic  subject,  that  state  demands  the  continuation  of 
the  alcohol  until  the  system  is  so  cleansed  from  toxic 
matter  as  not  to  be  in  danger  of  the  developing  delirium 
tremens. 

But  as  soon  as  that  danger  is  passed,  then  the  author 
would  urge  the  importance  of  discontinuing  the  use  of 


502  Narcotic  Drug  Diseases  and  Allied  Ailments. 

the  alcohol,  because  it  is  a  paralyzer  of  motion  and 
sensation,  interferes  with  the  inhibitory  control  of  the 
heart,  and  allows  that  organ  to  act  erratically  and  ex- 
travagantly, and  to  expend,  prematurely,  any  latent 
energy  which  the  system  may  have.  It  is  not  a  stimulant 
and  cannot  in  any  way  contribute  to  the  support  of  the 
patient. 

So  long  as  there  is  a  toxic  condition  of  the  system 
present,  the  sedative  effects  of  alcohol,  that  is,  its  para- 
lyzing effects  on  the  central  nervous  system,  are  the  best 
means  that  can  be  employed  in  alcoholic  subjects  to  make 
the  nervous  system  tolerate  the  presence  of  the  toxic 
matter  without  undue  rebellion. 

The  use  of  alcohol  for  this  purpose  does  not  interfere 
with  the  action  of  the  eliminating  organs  so  greatly  as 
does  the  use  of  any  other  narcotic ;  and  since  the  eliminat- 
ing organ  must  be  made  to  act  promptly  and  thoroughly 
in  order  to  overcome  the  toxic  condition,  all  forms  of 
opiate  or  restrictive  remedies  of  that  type  are  contra- 
indicated,  whereas  the  alcohol  itself  does  not  so  materi- 
ally interfere  with  the  action  of  eliminating  remedies. 
It  is  the  best  sedative  that  can  be  given  in  such  cases,  but 
it  should  be  continued  for  that  purpose  and  that  purpose 
only. 

It  should  not  be  necessary,  however,  to  keep  up  the 
alcohol  longer  than  four  or  five  days.  By  that  time  the 
system  should  be  so  cleansed  of  the  toxic  matter  that  the 
alcohol  should  be  gradually  and  rapidly  withdrawn.  It 
is  not  necessary  to  give  the  alcohol  in  such  large  quan- 
tities as  the  patient  may  have  been  taking  before  he  was 
attacked  by  the  acute  ailment,  but  if  he  was  drinking, 
say,  i  or  2  quarts  of  whisky  per  day  I  or  I  %  pints  would 
be  a  sufficient  quantity  to  have  all  the  sedative  effects  on 
the  nervous  system  that  is  usually  required. 


Alcohol  Not  Abruptly  Withdrawn.  503 

However,  in  case  delirium  is  threatened  it  is  better  to 
give  the  alcohol  in  larger  quantities,  if  necessary  to 
control  that  symptom.  The  central  nervous  system  may 
also  be  held  in  check  by  the  administration  of  gelsemi- 
nine,  veratrum,  or  other  motor  depressants.  These  give 
material  aid  in  preventing  an  attack  of  delirium  tremens. 
The  indications  for  treatment  as  the  author  sees  them 
in  such  patients  are: — 

First,  to  overcome  the  toxic  condition  which  is  pres- 
ent in  all  chronic  alcoholics. 

Second,  to  relieve  the  portal  engorgement. 
Third,  support  the  heart,  this  to  be  done  persistently 
and  systematically. 

Fourth,  prevent  complications,  such  as  delirium 
tremens. 

Fifth,  treat  any  feature  of  the  acute  ailment  which 
has  not  been  overcome  by  the  measures  employed  against 
the  toxemia. 

Purgation,  above  referred  to,  usually  meets  the  first 
two  indications,  that  of  freeing  the  system  of  toxic 
matter,  and  that  of  overcoming  the  portal  congestion; 
also  in  removing  the  obstruction  to  onward  flow  of  the 
blood-current  it  lessens  the  work  of  the  heart  and,  there- 
fore, materially  aids  that  organ  to  do  its  work. 

But  there  are  certain  remedies  which  can  be  used  to 
great  advantage,  and  which  give  the  heart  direct  and 
dependable  support.  For  this  purpose,  sparteine  sul- 
phate is,  in  the  author's  judgment,  by  far  the  most  satis- 
factory agent.  This  remedy  adds  tone  to  the  heart 
muscles  and  dilates  the  arterial  capillaries  in  such  a  way 
as  to  reduce  the  resistance  to  the  onward  flow  of  the 
blood-current  and  is  therefore  a  true  heart  tonic,  a  gen- 
erator of  heart  force.  It  also  materially  improves  the 
action  of  the  kidneys,  and  this  assists  in  overcoming  the 
toxic  condition. 


504  Narcotic  Drug  Diseases  and  Allied  Ailments. 

Strychnine  is  a  remedy  not  well  borne  in  this  class 
of  patients,  and  it  is  liable  to  precipitate  an  attack  of 
delirium  tremens;  therefore,  it  should  not  be  routinely 
employed,  and  not  at  all  where  there  is  any  tendency  to 
delirium. 

Sparteine,  caffeine,  normal  salt  solution,  digitalis, 
adrenalin,  and  strophanthus  are  all  remedies  which  may 
be  used  for  the  support  of  the  heart  without  danger  of 
establishing  delirium  tremens  from  their  effects,  but 
strychnine  usually  cannot  be  so  used. 

The  support  of  the  heart  should  be  begun  from  the 
very  beginning,  as  there  is  always  a  weak  heart,  whether 
it  be  due  to  loss  of  compensation  or  to  exhaustion  from 
overwork.  At  times  there  is  abnormally  low  blood- 
pressure  with  a  dilated  heart,  and  in  such  cases  digitalis 
and  adrenalin  prove  to  be  the  most  effective  cardiac  sup- 
portives.  But  where  arterial  tension  is  more  nearly 
normal,  caffeine,  sparteine,  and  normal  salt  solution  are 
much  to  be  preferred.  While  digitalis  adds  tone  to  the 
heart  muscle,  it  also  powerfully  contracts  the  arterial 
capillaries,  thus  raising  blood-pressure,  and  this  probably 
adds  as  much  resistance  to  the  onward  flow  of  the  blood- 
current  as  its  effect  on  the  heart  muscles  adds  to  the 
tone  of  that  organ.  Therefore,  it  is  doubtful  whether 
or  not  it  is  really  a  heart  tonic,  but  in  cases  where  there 
is  low  arterial  tension  it  is  an  ideal  remedy. 

As  a  respiratory  stimulant,  the  author  has  found 
cocaine  the  most  dependable  remedy  of  the  entire  list. 
He  has  usually  administered  it  in  %-  to  1/o-  grain  doses  at 
intervals  of  from  two  to  four  hours,  and,  in  many  cases 
where  the  respiration  was  persistently  embarrassed,  this 
symptom  had  entirely  disappeared  upon  the  administra- 
tion of  the  cocaine,  and  had  not  reappeared  as  long  as 
the  system  was  uniformly  kept  under  the  influence  of 
that  remedy. 


INDEX. 


Abortion,    threatened,    as    cause    of 

addiction,  311 
Abstinence     symptoms     avoided     by 

treatment,  64 

cannot  be  long  concealed,  33 
cause  of,  12 

Accidental  causes  of  morphinism,  22 
Accommodation,  effects  of  opiates  on, 

29 
Acid,  hydrochloric,  excess  of,  due  to 

underconsumption,  394 
excess  of,  not  the  pathology,  394 
Acute    ailments,    how    influenced    by 

use  of  drug,  336,  337 
in  alcoholic  subjects,  494 

indication    in   treatment,  503 
use  of  alcohol  during  treat- 
ment of,  501 
treatment   of,   in   drug  habitues, 

336 
Addiction,  history  of,  in  physicians, 

27 

formed,  at  times,  without  any  ele- 
ment of  dissipation  or 
other  blameworthy  motive, 
27 

how  formed,  287 
justifiably  formed,  309 
time  required  to  confirm,  variable, 

23 

After-treatment  does  not  consist  of 
administration  of  drugs, 
197 

alcohol  in,  bad  effects  of,  56 
strychnine  in,  bad  effects  of,  56 
Age,   advanced,   affects  progress  fa- 
vorably, 280 
not  bar  to  treatment  of  addiction, 

137 

Alcohol,  a  depressant,  495 
appetite  for,  leads  to  use  of,  444 


Alcohol,  dangerous  for  ex-drug  ha- 
bitues, 283 

dangers  of,  De  Quincy,  360 

dependence  of  habitue  on,  455 

immediate   withdrawal,   dangerous, 
466,  477 

mental   attitude   of  patient  impor- 
tant factor,  455,  457 

not  a  stimu  ant,  497 

retards  elimination,  497 

routine    treatment    not    successful, 
473 

useful  in  delirium  tremens,  489 
Alcoholic  subjects,  acute  ailments  in, 

494 
prognosis   of  acute   ailments   in, 

494,  498 
treatment  of  acute   ailments   in, 

494 
Alcoholism,  acute,  treatment  of,  447 

advantages    of    institutional   treat- 
ment, 456 

as  seen  by  a  surgeon,  467 

bad  environment  leads  to,  443 

by  B.  C.  Keister,  463 

by  C.  A.  McBride,  469,  473 

by  Chas.  A.  Rosenwasser,  465 

by  Howard  A.  Kelly,  467 

catarrh  of  the  stomach,  treatment 
of,  450,  451 

chronic,  a  disease,  434,  461,  473 

classification  of,  435 

curability  of,  463,  466 

delirium  in,  476 

details  of  treatment  of,  447,  450 

emetic  treatment  objectionable,  459 

etiology,  435,  437 

gelseminine  in,  value  and  use  of, 
449 

(505) 


506 


Index. 


Alcoholism,  home  life  not  favorable 

for  treatment,  457 
home  treatment  a  fallacy,  458 
ichthyol  in,  451,  455 
in  treatment,  patients  must  be  indi- 
vidualized, 473 
instability    of    character    leads    to, 

443 

moral  cowardice  leads  to,  442 
Norman  Kerr's  views,  461 
periodical,  440 

principles  of  treatment  of,  445 
prognosis  in  different  classes,  439 
regular  drinkers,  435 
structural  lesions  of,  463,  465 
three-day  cure  of,  a  fallacy,  458 
treatment   of,   in    secrecy   not   ad- 
vised, 456 
some  cases  simple,  some  difficult, 

447,  546 
what  constitutes  rational  treatment, 

460 

Ambition,   inordinate,  leads  to  mor- 
phinism, 20 
Anemic  type  of  delirium  tremens,  478, 

479 
Animal  food  should  be  taken  at  one 

meal  a  day,  265 
Antipyretic  effects  of  quinine  in  drug 

patients,  234 
Antipyretics,     useless     and     helpful 

ones,  48 

Antitoxin,  none  available,  57 
Apomorphine    in    delirium    tremens, 

489 
Appetite,   a   creature   of   cultivation, 

265 

after  withdrawal  of  opiates,  49 
for  alcohol  leads  to  use  of,  444 
grows  by  what  it  feeds  upon,  265 
not  safe  guide  to  needs  of  system, 

265 
Arterial  tension  high,  109 

reduced   by  treatment,    109,    110, 

121,  122 

Aspirin,   a    reliable    antipyretic,  226, 
227 


Aspirin,  in  drug  cases,  230 

use  and  value  of,  48 
Atropine  a  valuable  addition  to  pur- 
gatives, 155 

aids   strychnine    in    inducing   peri- 
stalsis, 157 

effect  on  intestinal  motion,  155,  156 
habitues    show   great    nervousness, 

36 

users  of,  in  constant  motion,  37 
Author's  method  of  treatment  of  de- 
lirium tremens,  476 
Authors,  responsibility  of,  192 
Automatic  element  of  habit,  5 

Beer  and  wine  drinkers  differ  from 

other  alcoholics,  495 
Belladonna,   effect  on   intestinal  mo- 
tion, 155 
Bertrand,  Dr.,  published  first  case  of 

hypodermic   addiction,   2 
recommended     hypodermic     ad- 
ministration   of    morphine 
in  1836,  2 

Bile,  toxicity  of,  58 
Bismuth,  with  test-meal,  radiograph, 

163 

Blood,  circulation  of,  forces  govern- 
ing, 236,  237 
in  morphinism,  8 
Blood-pressure,      during     treatment, 

122,  127 

high  on  admission,  99 
in  asthenic  type  of  delirium  tre- 
mens, 485 

modified  by   treatment,   99,   100 
Bowel,    difficulty    in    securing   action 

of,  101 

motor    function    of,    greatly    im- 
paired, 52 

overdistention  of,  avoided,  154 
practically    normal    evacuation    of, 

artificially  induced,  153 
Brain-  or  nerve-  lesion  not  pathology 
of  addiction,  7 

Cannon,  conclusions  as  to  movement 
of  colon,  164 


Indc.v. 


507 


Case  reports  in  detail,  10,  81,  85,  91, 

93,  100,  111,  129 
Catarrh    of    the    stomach,   alcoholic, 

treatment  of,  450,  451 
Cells,  the  ultimate,  toxins  in,  47 
Cerebral  sedatives  in  delirium  tre- 

mens,  483 
Character,  defective  traits,  increased 

by  the  use  of  drug,  319 
instability  of,  leads  to  alcoholism, 

443 

leads  to  morphinism,  20 
Chemical    stimulation    of    secretion, 

145 

Child  in  uterus  an  habitue,  324,  325 
Children       born       of       opium-using 

mothers,  328 

administration  of  drug  to,  330 
can  be  saved,  333 
how  saved,  333 
management  of,  328,  329 
mortality  of,  331 
Chloral  addiction,  24 
Chloroform  addiction,  25 
Chronic  alcoholism,  434 
a  disease,  461,  473 
classification  of,  435 
Cinchonism    readily    induced   by    in- 
unction   with    glycerol    of 
quinine,  232 

Circulation,  forces  governing,  236,  237 
Cocaine,  dangers  of  use,  426 
abrupt  withdrawal  of,  428 
habit,  425 

prognosis  of,  431 
treatment  of,  428 
habitues,  behavior  of,  35,  36 
in  carbonated  drinks,  427 
mode  of  use,  425 
not  substitute  for  morphine,  433 
one  who  uses  dangerous,  426 
prolonged     sleep      follows     with- 
drawal, 429 
Cocaine  and  morphine,  combined  use 

of,  428,  433 

Codeine     addiction     essentially     the 
same  as  any  other  opiate,  3 


Coercion  not  necessary,  but  hurtful, 
43 

Coffee  and  tea  hurtful,  284 

Cold  pack,  advantage  of,  195 

Colic  following  the  withdrawal,  cause 
of,  13 

Collapse,  cause  of,  44 

Colon,  ascending  motility  of,  164 
office  of,  165 

Comparison  of  results,  97 

Comradeship  with  other  convales- 
cents, advantage  of,  197 

Concealed  morphinism  in  parturient 
women,  324,  325 

Condition  of  blood  in  delirium  tre- 
mens,  481 

Confidence  of  patient,  means  of  se- 
curing, 296,  297 

Congenital  morphinism,  324 

Control  of  delirium  essential  in  de- 
lirium tremens,  488 
in  anemic  cases  of  delirium  tre- 
mens, 484 

Convalescence  shortened  and  made 
more  certain,  55 

Conviction,  lack  of,  leads  to  mor- 
phinism, 31 

Courage  and  conviction  essential 
qualities  to  enable  physi- 
cian to  succeed  in  drug 
cure,  71 

Cowardice,  moral,  leads  to  morphin- 
ism, 20 

"Craving"    for    narcotics    a    "straw 

man,"  407 

elements  of — Jennings,  383,  387 
overcome    by    proper    treatment, 
54 

Crittenden's  dietary,  experiments  of, 
273 

Crother's  condemnation  of  hyoscine, 
103,  108 

Crucial  test  of  narcotic  addiction,  32 

Curability  of  alcoholism,  462,  466 

Cure,  desire  for,  of  drug  users,  322, 
323 


508 


Index. 


Cure  is  not  complete  when  drug  is 

withdrawn,  65 
permanency  of,  what  is  necessary 

to,  65,  275 

time  required  for,  181 
what  constitutes,  178,  181 

Daturine,  action  of,  170 
duration  of  effect  of,  170 
effect  of,  on  mucous  membrane,  170 
Daturine  and  hyoscine  compared,  170 
De  Quincy's  writings  led  to  use  of 
cruder  forms  of  opium,  6 

popularize  and  increase  habitual 

use  of  opiates,  1 
Degeneracy,  erroneous  opinions  as  to, 

321 

Delirium  during  treatment,  how  con- 
trolled, 103 

tremens,     sudden     suppression     of 
alcohol  likely  to  cause,  489 

anemic  type,  478,  479 

apomorphine  in,  489 

author's    method    of    treatment, 
476 

blood-pressure   in   asthenic   type, 
485 

cerebral  sedatives  in,  485 

classification  of  cases,  478 

condition  of  blood  in,  481 

control  of  delirium  essential,  488 

control    of    delirium    in    anemic 
cases,  484 

control  of  delirium  in  hyperemic 
cases,  482 

elimination  principal  curative  fac- 
tor, 480 

gelseminine  in,  479 

hyoscine  in,  479 

hyperemic  type,  478,  479 

hypnotics  in,  489 

in  hyperemic  type,  stimulants  in- 
crease delirium,  479 

indication   of  treatment   recapit- 
ulated, 492 

indication  to  be  met  in  treatment, 
476 


Delirium  tremens,  morphine  in,  479 
mortality  should  be  low,  490 
mortality  under  usual  treatment, 

477 

normal  salt  solution  in,  480 
pathology,  476 

per  cent,  of  hyperemic  cases,  479 
pulse    tracings    showing    arterial 

tension  restored,  488 
pulse  tracings  showing  low  arte- 
rial tension,  486 
purgatives  in,  480,  481 
results  of  treatment,  490 
strychnine  and  hyoscine  indicated 

in  anemic  cases,  484 
strychnine  in,  479 
support  of  heart  in,  481 
use  of  alcohol  in,  489 
veratrum  in,  491 
Dependence    of    habitue    on    alcohol, 

455 

Depletion  avoided  by  properly  com- 
pounded purgatives,  157 
Diarrhea,  cause  of,  44 
if  not  prevented,  exhausts  patient, 

91 

modes  of  preventing,  91 
Diet  during  convalescence,  261 
erroneous  teachings  as  to,  49,  50 
liberal,  raises  blood-pressure,   118 
low  calorie,  best  for  drug  patients, 

265 

examples  of,  273 
tests  of,  273 

proper  proportion  for,  267 
study  of,  by  Fletcher,  273 
Dipsomania,  441 
Direct  stimulation  of   secretion   and 

motion,  146 

Discharge,  time  for,  182 
Dissipation,  use  of  opiates  rarely  be- 
gins as  such,  306 

Drug,  demand  for,  continued  use  due 
to    toxic    state    caused    by 
drug,  6 
desire  for,  overcome,  78 


Index. 


509 


Drug,  heroic  efforts  to  stop  use  of, 

313,  314 

habitues  desire  to  be  cured,  294,  295 
lack  of  faith  in  other  drugs,  285 
necessary  to  habitues,  303 
often  combined  by  habitues,  34,  35 
Drug     addiction     among    physicians, 
mode  of  development  and 
reason  for,  40 

both    mental    and    physical    ail- 
ment, 293 

curability  of,  293,  295 
from  acute  ailment,  131 
in  pregnant  women,  128,  129 
long-standing,  232 
Drug    users,    attitude    of    profession 

toward,  190 

many  retain  good  reputation,  308 
misjudged,  305 
not  all  untruthful,  16 
should  be  quininized  when,  234 
untruthfulness  of,  due  to  other 

causes  than  drug,  16 
Dumb-bells,  objections  to,  238,  239 
Duration  of  addiction   affects  prog- 
nosis, 281,  282 
not  material,  139 

Electric   stimulation  of  motility  and 

secretion,  150 
Elimination  and  time  cure  addiction, 

88 

details  of,  59,  60,  61 
origin  of,   in  treating  drug  cases, 

195 

principal  curative  factor  in  treat- 
ment of  delirium  tremens, 
480 

Emetic  treatment  objectionable  in 
treatment  of  alcoholism, 
459 

Environment,  bad,  leads  to  alcohol- 
ism, 443 
Ergot,  Livingston's  claims  for,  229 

an  unreliable  remedy,  229 
Erlenmeyer,  writings  of,  362,  365 
Erroneous  claims  of  Lott,  73 


Errors  in  method,  285 

in  pathology,  286 
Excretion,     deficient,     causes     many 

complications,  44 
Excretion  and  secretion,  influence  of 

drug  on,  338 
Exercise,  time  for  taking,  242 

Failure  in  treatment,  some  reasons 
for,  285 

Fever    following    withdrawal,    cause 

explained,  12,  14 
how  controlled,  48 

Flesh,  newly  acquired,  an  encum- 
brance if  not  converted 
into  muscle,  198 

Fletcher,  dietary  practice,  273 

Food,  much  more  than  necessary  con- 
sumed, 274 

substance,  classes  of,  262 
value  of,  in  calories,  268,  269,  270, 
271 

Formulae  for  purgative,  166 

Functional  disease,  existence  of,  only 
recently  admitted,  8 

Games,  advantages  of,  197,  198 
Gelseminine,  dose  of,  224 
a  cerebral  sedative,  224 
a  motor  depressant,  224 
full  effects  of,  225 
in  alcoholism,  value  and  use  of,  449 
in  delirium  tremens,  479 
General    hospital    not    suitable    place 

for  patients,  64 
Glandular  stimulants,  large  quantities, 

not  required,  53 

Glycerin,  the  proper  vehicle  for  qui- 
nine inunction,  231 
Glycerole  of  quinine,  valuable  thera- 
peutic agent,  332 
formulas  for,  233 
Gradual  reduction,  cause  of  relapse, 

290 

dangerous  nature  of,  286 
effect  of,  on  mind  of  patient,  289 
fallacy  of,  290 


510 


Index. 


Gradual    reduction,    leading    feature 

of,  289 
method  indorsed  by  most  writers, 

39 
perpetuates  addiction,  291 

Habit  defined,  5 
how  overcome,  6 
-producing  drugs  defined,  6 
Habitual  use  of  drug  only  as  symp- 
tom of  real  condition,  6 
Hare's  claims,  effects  of,  78 

reviewed,  77 
inadvertent  claims,  76 
Heart  action,  deficient,  due  to  portal 

engorgement,  54 
during  treatment,  112,  114 
effect  of  treatment  on,  56,  57 
following  withdrawal,  46 
labored,  a  deficient  cause  of,  44 
sustained  by  treatment,  113,  121, 

130,  135 
break    of    compensation    in    acute 

alcoholism,  495 

lesion  not  bar  to  treatment  of  ad- 
diction, 135 

overtaxed   by   heavy-weight   exer- 
cise, 239 

support  of,  in  delirium  tremens,  482 
Hepatic   colic,   large   doses   of   mor- 
phine required  in,  71 
Heroin  addiction  established  same  as 

other  opiates,  3 

longer  time  required  to  form,  4 
Hertz,  action  of  salines,  162 
Home  of  patient  not  place  for  treat- 
ment, 195 
treatment  of  alcoholism  a  fallacy, 

458 

Hydrochloric  acid  in  drug  cases,  227 
not  present  in  excess,  398 
often  deficient  after  withdrawal, 

228 

prevents  hyperacidity   from    fer- 
mentation, 228 
underconsumption  of,  398 
Hyoscine  addiction,  24 


Hyoscine,   administration   to   infants, 

327 
administration  to  pregnant  women, 

135 
aids    in    restoring   mental    activity, 

172 

as  secretory  stimulant,  171,  172 
dose  for  infant,  327 
effect  on  respiration,  169 
effects  of  prolonged  administration, 

184 

erroneous  ideas  as  to  use  of,  72 
excessive  use  of,  173,  179 
great  intolerance  for,  82,  86 
habitual  tolerance  for,  87 
length   of   time    required    in    drug 

cases,  87 

no  fixed  dose,  55 
not  an  antidote  for  morphine,  94 
office  and  value  of,  75 
prolonged     administration,     some- 
times    causes     intolerance 

for,  95 

scopolamine,  action  of,  168 
susceptibility  to,  varies  greatly,  79 
toxic  effects  of,  examples,  80,  81 
use  in  delirium  tremens,  479 
when  to  be  given,  62 
Hyperemic  type  of  delirium  tremens, 

478,  479 
Hypnotics,  use  in  delirium  tremens, 

489 

Ichthyol,  in  alcoholism,  451,  455 
mixture,  formulae  for,  454 
physiological  effects  of,  453 

Immediate  withdrawal  of  alcohol  in 
delirium  tremens,  489 

Immorality  forced  by  withholding 
drug  supply,  316 

Inadvertent  formation  of  addiction 
defined,  22 

Indication  to  be  met  in  treatment  of 
delirium  tremens,  476 

Indications  in  treatment  of  acute  ail- 
ments in  alcoholic  sub- 
jects, 503 


Index. 


511 


Instability  of  character  leads  to  alco- 
holism, 443 

Institution,   advantages  of,   in  treat- 
ment, 193 
best  place  for  convalescence  as  well 

as  for  treatment,  49 
Intestinal  contents,   downward  pass- 
age of,  146 
motion  suspended  by  morphine,  14 

excited  by  strychnine,  153 
Inunction     a     prompt     and     reliable 
method  of  securing  effect 
of  quinine,  232 
Itching  of  nose  caused  by  opiates,  31 

Jennings,  Oscar,  elements  of  craving, 

303 

opinions  of,  379,  381 
writings  of,  369,  377 
Judgment,  a  plea  for  a  more  just,  of 

narcotic  drug  users,  303 
Justifiable  use  of  morphine,  19,  20 

Keister,  B.  C,  on  alcoholism,  463 
Kelly,  Howard  A.,  on  alcoholism,  467 

Lambert,    Alexander,    comments    on 

writings  of,  415,  424 
objections   to   teachings  of,  423, 

424 

views  of,  407 

Literature,  review  of,  347,  401 
Lott,  credit  erroneously  given  to,  74 

painless  cure,  examples  of,  74 
Lett's  claims  reviewed,  77 

Malarial  complications,  how  managed, 
99,  100 

Massage    of    abdomen    excites    peri- 
stalsis, 148 

McBride,  C.  A.,  on  alcoholism,  469 

McBride's  surgical  treatment  of  alco- 
holism, 473 

Meals  for  drug  patients,  examples  of, 
264 

Measurements  for  body  of  men,  241 
of  women,  241 


Meat  diet  not  best  for  drug  and  alco- 
holic patients,  265 

Mechanical  devices  for  physical  exer- 
cise, 258,  260 

stimulation,  benefit  of,  397 
of  motor  and  secretory  functions, 

147 
substitute    for   drug   stimulation, 

38 
Mental  attitude  of  patient  important 

factor,  445,  447 
impression,  effect  of,  291 
state  dominates  men,  292 
Mental    condition    of    drug   patients, 

development  of,  288 
element    of    drug    cases,    manage- 
ment of,  296 
impression,  power,  and  duration  of, 

291,  299,  300 

Mind,  effects  of  hyoscine  on,  186,  187 
Mode  of  use,  influences,  time  required 

to  confirm  addiction,  23 
Mood,  variability  of,  in  drug  users, 

30 
Moral  cowardice  leads  to  alcoholism, 

442 

purpose,  lack  of,  leads  to  morphin- 
ism, 21 

Morphine,  effect  of,  on  nervous  sys- 
tem, 13 
contraindicated    in     delirium    tre- 

mens,  479 

disease  defined,  3,  4 
effects  of  habitual  use  of,  on  con- 
ception, 16 
on  perception,  IS 
on  system  analyzed,  12,  IS 
essential  nature  of,  3,  4 
from  proprietary  nostrums,  22 
habit,    opium    habit,    use    of   term 

condemned,  5 
inadvertently  formed,  22 
its  discovery  and  hypodermic  use, 

addiction,  2 

its  use  in  delirium  tremens,  479,  490 
not  a  vice,  10 
not  an  antidote  for  hyoscine,  94 


512 


Index. 


Morphine,    use    of,    in    hepatic    and 

renal  colic,  20 

withdrawal  from  infants,  328 
withdrawal  of,  from  infant,  327 

Morphine    addiction,    mechanism    of 

formation,  12 
time  required  to  form,  18 

Morphine  and  atropine  habitues  nau- 
seated by  morphine,  37 

"Morphine  fiend,"  use  of  term  con- 
demned, 321 

Morphinism  a  disease,  191 
defined,  3,  4 

Morphinist  compared  with  morphino- 
mania,  4 

Mortality  should  be  low  in  delirium 

tremens,  477 

under  usual  treatment  of  delirium 
tremens,  477 

Motive  fixes  moral  quality  of  act,  321 

Motor  function  of  intestine  chiefly 
impaired,  339,  341 

Muscles,  alternate  tension  and  re- 
laxation of,  238 

Muscular  tension,  effect  of,  238 

Narcotic  addiction,  complications  dur- 
ing treatment,  52 
crucial  test  for,  52 
essential  pathology  of,  52 

Narcotics,  use  of,  conditions  predis- 
posing to,  18 

Nausea  and  vomiting,  as  abstinence 
symptom,  14 

Nerve-  and  brain-  lesion  not  pa- 
thology of  narcotic  addic- 
tion, 7 

Nerve-centers    profoundly    lethargic, 

53,  153 

mechanism    of,    stimulation    of, 
156 

Neutral  bath,  value  of,  195 

Non-habit-producing  drugs  defined, 
6 

Normal  salt  solution,  its  use  in  de- 
lirium tremens,  480 


Oily  substance  not  fit  vehicle  for  qui- 
nine inunction,  231 

Opiates,  use  of,  does  not  beget  de- 
generacy, 307 

withdrawn  during  convalescence 
from  acute  ailment  in 
which  addiction  is  formed, 
130 

Opinions,  the  holding  of  certain,  un- 
fits physician  for  treating 
drug  cases,  194 

Opium  habit,  morphine  habit,  use  of 
term  condemned,  5 

Opium  habitues  rarely  ever  sneeze,  31 

Osier's  "Modern  Medicine,"  extract 
from,  404 

Overconfidence  in  powers  of  self- 
control  leads  to  addiction, 
20,  26 

Overeating  dangerous  for  drug  pa- 
tients, 262 

Overwork  leads  to  addiction,  25 

Pain     during     convalescence,     how 

avoided,  45 
Pains    of    opium,    De    Quincy,    354, 

359 

Pathogenesis  of  drug  habit,  7 
Pathology,  erroneous  views  of,  39 
of  delirium  tremens,  76 
of  narcotic  addiction,  7,  9 
Peristalsis  essential  to  bowel  move- 
ment, 339 
mechanism  of,  152 
normal,  152 

normal,  artificially  induced,  153 
suspended    by   primary    effects    of 

opiates,  59,  152 

Personality  of  physician  important 
factor  in  treatment  of  drug 
patients,  302 

Perspiration,     excessive    and    irreg- 
ular, indicates  addiction  to 
narcotics,  32 
toxicity  of,  58 

Physical  ailments  which  contribute  to 
use  of  morphine,  19 


Index. 


513 


Physical  examination  of  patients,  ob- 
jects of,  297 
restraint  damaging,  314 
training,  235 

examination  before,  239 
modified  forms  of,  necessary,  235 
physiological  effect  of,  236 
preparation  for,  239 
value  of,  in  drug  cases,  235 
Physicians    largely    responsible     for 

addiction,  22,  23 
Physiological   effects   of   ichthyol    in 

alcoholism,  453 

stimulation   of    secretion   and   mo- 
tion, 150 
Pilocarpine  as  an  antipyretic,  225 

hypnotic,  226 
may  cause  nausea,  226 
use  and  value  of,  49 
use  of,  in  drug  cases,  225 
Pleasures  of  opium,  De  Quincy,  347, 

352 

Portal  engorgement  important  factor 
in  causing  complication,  44 
must  be  overcome  before  with- 
drawal, 44 
Pregnancy  not  bar  to  treatment  of 

addiction,  128,  129 
withdrawal  during,  325 
Prognosis,  favorable  in  majority  of 

cases,  278,  279 
heretofore  considered  unfavorable, 

278 

in  drug  cases,  275 
influenced  by  origin  of  addiction, 

277 

by  duration  of  addiction,  282 
Psychic  state,  patients  in,  action  on 

suggestion,  300 
may  be  induced  by  scopolamine 

or  hyoscine,  300 
nature  of,  300 

patients  in,  do  not  reason,  300 
Public  opinion,  errors  of,  307 

influence  of  drug  user  on,  306 
Pulse  of  morphine  habitue  in  state 
of  want,  217 


Pulse  of  morphine  habitue  restored 

by  morphine,  210 
by  sparteine,  210 
Pulse  tracings,  during  treatment,  110, 

114 

in  morphinism,  109,  110 
showing  arterial  tension  restored 

in  delirium  tremens,  488 
showing  low  arterial  tension  in 

delirium  tremens,  486 
Pupil,  effects  of  cocaine  on,  29 
of  hyoscine  on,  29 
of  opiates  on,  29 

Purgative  for  narcotic  habitues,  157 
Purgatives  for  pregnant  women,  128, 

129 

in  delirium  tremens,  480,  481 
principles  upon  which  they  act,  142, 

145 

repetition  of,  61,  62 
schematic  diagram  for,  158 
unphysiological,  413 
unpleasant    effects     of,     on     drug 
habitues,    explanation    of, 
68 

Purge,  a  physiologically  balanced,  59 
physiologically    balanced,     defined, 
157 

Quinine  an  antipyretic,  234 
by  inunction,  230 
in  drug  cases,  229,  230 
in  large  doses  a  sedative  in  certain 

conditions,  234 
inunction     essentially    a    chemical 

process,  232 
principles  governing,  231 

Reduction   method,   damaging   effect 

of,  279 
of    doses,    how    and    when    to    be 

made,  61 
Reflex  stimulation,  local,  144 

not   sufficient  to   excite    efficient 
peristalsis  in  drug  cases,  53 
Relapse,  must  be  fortified  against,  197 
Relapses,  other  causes  of,  283 


514 


Index. 


Relief,  demand  for  immediate,  cause 

of  drug  habit,  10 
the  most  frequent  cause  of,  282 
Reputation     of     drug     users,     how 

formed,  319 

Resistance  work,  details  of,  243 
effect  of,  on  circulation,  236 
effect  on  nutrition,  236 
Respiration,  deep  abdominal,  excites 

peristalsis,  149 

Restraint  not  helpful,  181,  182 
Review  of  literature,  347,  401 
Rosenbery,  excessive  use  of  hyoscine, 

173,  174 

Rosenwasser,   Chas.   A.,   on   alcohol- 
ism, 465 

Routine  treatment  not  possible,  65 
not  successful  in  alcoholism,  473 

Saline  cathartics,  action  of,  161 
solution,  value  and  use  of,  81,  82 
time   of   passage    through    intes- 
tines, 163 
Scopolamine,   causes  "psychic"   state, 

300 

dose  of,  55 
effect  on  heart,  169 
effect  on  intestinal  motion,  155 
effect  on  respiration,  169 
office  and  value  of,  75 
proper    therapeutic    use    does    not 
perpetuate  demand  for  opi- 
ates, 54 

when  to  be  given,  62 
Scopolamine  and  daturine,  compound, 

170 
Scopolamine,    hyoscine,    identity    of, 

168 
Secretion,    secondary  stimulation  of, 

by  hyoscine,  72 

stimulants,    large    doses    not    re- 
quired, 53 
Secretory    function,    stimulation    of, 

144,  145 

Self-defense  prompts   denial  of  ad- 
diction, 321 


Self -recovery   no    tendency    in    drug 

addiction,  140 

Selfishness  leads  to  morphinism,  21 
Simplex  exerciser,  258,  260 
Skin,  effects  of  opiates  on,  31 
Sleep,  produced  by  hyoscine,  62,  63 

produced  by  Scopolamine,  62,  63 
Sneezing  rare  in  opium  habitues,  31 
Sodium  bicarbonate,  use  of,  by  Jen- 
nings, 391 

explanation  of  effects  of,  395 
Sodium  hyposulphite,  use  of,  63 
Sparteine,  a  true  and  reliable  heart 

tonic,  202 

adds  tone  to  heart  muscle,  202 
as    a    non-irritating    diuretic,    213, 

218 

comparative  value  of,  218 
compared    to    digitalis    and    vera- 

trum,  201 
corrects     irregularities     of     heart 

action,  202 

decreases  blood-pressure,  203,  205 
dose  of,  199,  200 
duration  of  effects,  201 
effect  on  capillary  circulation,  218 
on  blood-pressure,  201,  202,  205 
in  acutely  dilated  heart,  215 
in  pneumonia,  212 
in  postoperative  suppression,  218 
is  the  alkaloid  of  Cysticus  scopa- 

rius,  217 

Jennings's  study  of,  208 
no  hurtful  after-effects,  212 
non-toxic  drug,  200 
overcomes  venous  stases,  212 
pain  from,  reduced  by  slow  injec- 
tion of  dose,  223 
physiological  effects  of,  201,  202 
promotes   healing  after   operation, 

219,  222 

promptness  of  action,  201 
reduces  postanesthetic  nausea,  219 

222 

reduces  heart  strain,  212 
reduces  surgical  shock,  219,  221 


Index. 


515 


Sparteine    succeeded    when    digitalis 

and  strychnine  failed,  214 
under    some    conditions    increases 

pulse  rate,  204 
usually    slows    heart    action,    203, 

204 

valuable  in  surgical  work,  219 
Specific   of   Lambert   not   a   specific, 

410,  411 

Stimulants  increase   delirium  in  hy- 
peremic   type    of    delirium 
tremens,  479 
Stomach,  digestive  capacity  of,  after 

withdrawal,  49 
should    be    empty    before    giving 

purge,  159 

should    be    protected    from    over- 
work, 264 
should    not    be     overtaxed    after 

withdrawal,  49 

Strength    of    patient,    necessity    and 
method  of  consuming,  58 
Structural  lesion  of  alcoholism,  463, 

467 
in  morphinism  not  demonstrable, 

7 
Structural    pathologists,    effects     of 

their  treating,  8,  9 
Strychnine,  after-effects  of,  66,  67 
an   essential   ingredient   in   purga- 
tive, S3 

failure  to   administer  in  sufficient 
doses     brings     failure     in 
treatment,  69,  70 
in  delirium  tremens,  479 
in  large  doses  may  be  given,  67 
in  sufficient  doses  will  excite  peri- 
stalsis in  opium  habit,  53 
larger    than    medicinal    doses    re- 
quired, 66 
quantity  required  in  drug  users,  340 
susceptibility  or  intolerance  for,  65 

how  determined,  65 
tolerance  for,  explained,  66 
Strychnine  and  atropine,  effect  of,  on 
intestinal  motion,  156 


Strychnine  and  hyoscine  indicated  in 
anemic   cases   of   delirium 
tremens,  484 
Suffering  during  treatment  should  be 

avoided,  55 
during  and  after  withdrawal,  how 

prevented,  45 

Suggestive  treatment,  value  of,  298 
Supervision      during      convalescence 

needed,  49 
Support  of  heart  in  delirium  tremens, 

481 

Surgeon's  views  of  alcoholism,  467 
Susceptibility     to     hyoscine     varies 

greatly,  79 

Sympathy     damaging     during     con- 
valescence, 195 

Symptomatic  treatment  of  morphin- 
ism a  fallacy,  9 

Symptoms  of  gradual  reduction  de- 
scribed by  Dr.  Wilson,  37 
during  convalescence,  45,  47 
indicating  deprivation,  37 
indicating  use  of  opiates,  29 
indicating  use  of  other  drugs  with 

opiates,  34 
of  gradual  reduction  described  by 

Erlenmeyer,  38 
of  morphinism,  28 
of  sudden  pressure,  41,  42 
which  develop  under  gradual  with- 
drawal, 30 

Teachings  of  Lott  and  Hare,  88,  89 
Temperature,    following  withdrawal, 

cause  of,  13,  14 
rise  of,  from  withdrawal  of  drug, 

13,  14 

Tobacco,  use  of,  hurtful,  284 
Toxemia,  acute  intestinal,  almost  un- 
avoidable, 118,  119 
effect  of,  119 
example  of,  118 
treatment  of,  120 

Toxic  diathesis  an  element  in  habit- 
ual use  of  narcotics,  6 
Toxicity  of  urine,  58 


516 


Index:. 


Toxin,   elimination   of,   only   remedy 

of,  57 

Toxins,  complex  nature  of,  57 
Treatment,  details  of,  60,  64 
long-continued  damaging,  290 
modification  of,  98 
obsolete  ideas  as  to,  405 
of  addiction  more  than  mere  prac- 
tice of  therapeutics,  302 
of  morphinism,  183 
older  methods,  285,  286 
principles  of,  51,  54 
principles  of,  by  Jennings,  387 
safety  of,  shown  by  pulse-tracings 
and  blood-pressure  records, 
98 
to  be  successful  must  correct  mania 

of  patient,  290 
Turkish  baths,  suggested  by  Jennings, 

392 
Types  of  drug  users,  315,  316 

Untruthful,  drug  users  not  all,  16 
Untruth  fulness  not  due  to  effects  of 

drug  alone,  16 
other  influence  than  drug  cause  of, 

16 
Use,  longest  continual,  of  morphine, 

139 


Use  of  alcohol  during  treatment  of 

acute  ailments,  501,  502 
in  delirium  <remens,  489 

Value  and  use  of  gelseminine  in  alco- 
holism, 449 

Veratrum  in  delirium  tremens,  491 

Veronal  in  drug  cases,  objections  to, 
228 

Vice,  narcotic  addiction  erroneously 
so  classed,  10 

Waugh  suggested  use  of  calomel,  193 
Weight,   too   rapid   increase,   an  en- 
cumbrance, 50,  91 
Withdrawal,  condition  following,  303, 

305 

Erlenmeyer's  rapid  method,  365 
symptoms  accounted  for,  11,  13,  304 
without  danger  or  severe  suffering 
if  patient  is  properly  pre- 
pared, 43,  44 

without   elimination,   examples   of, 
370 

Youth,  affects  prognosis  unfavorably, 
280,  281 

Zigzag  or  tacking  course  of  cocaine 
habit,  34,  35 


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